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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 9533--7{697 FOR INSPECTIONS �EXPIIRRE�S 1 EAR FROM DATE ISSUED JOB ADDRESS • V CICITY/ZIP Iq 1�/L^J�' ' CROSS STREET APN lJ n / �' �'"'t'AR L SIZE O- t l �n d I OWNER NAMEy PHON G� OWNER ADDRESS 4/ A �2"64 CITY/STAT IP CONTRACTOR �Ir— PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I I IC-42 I_I'IC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH?�w C0 sf, GEOGRAPHICAL INFORMATION: Coordinates X Y r 1-1 PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION i REPAIR/ADDITION f ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE 1 I COMMERCIAL1-1 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY O gal #OF COMPARTMENTS_ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL N-4292 ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE O NEAREST WELL ft FOUNDATION FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTHLA- ft LENGTH__ `` l/ ft DEPTH If �y j6 !?7--ft / DISTANCE TO NEAREST WELL �,�DN� ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW MINI H ADVANCE NOTICE UIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE O DATE off EAT 44 AAbn1 E vI h E L EPARTMEN SE NLY Application Accepted B Date Area Employee ID# Final Inspection By Date SPEC AL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PiVSump Soil aracter: COMMENTS71J,1ef=72T-; VAIUMIEPHIAAzD, fVO In,Y�f.t, ansE 0 k4f"/ (00' Cf MP0 W L 1- Zo PE SC Received Check,W Amount Date Permit/ Invoice# Permit ID# Code INFO B sh Remitteo ervice Re uest# (LIin. ONPW 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17