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I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT f ' SAN JOAoum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 NON-REFUNDABLE PERMIT CALL 209 953--7697FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB AwFtESs�// �� 1 3 iJ�-C �ii�-A 1'Y"_..__ ......_CITY/Z1P !', +• `� j� 7" CROSS STREET _ APN PARCEL SIZE OWNER NAME r ) �+7�/yM��i' PHONE_, OWNER ADDRESS �.-J�... �_...._C_.f15TATE1P ,2r y I!v u._4 CONTRACTOR PHONE CONTRACTOR ADDRESS LICENSE �E-42 ',..i:.C-36 OTHER NUMBER L. EXPIRATION DATE WATER TABLE DEPTH: .r" V it GEOGRAPHICAL INFORMATION: Coordinates X, Y E! PERC TEST # BUILDING PERMIT# LAND USE APPLICATION TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED(ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: a RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:------- __ NUMBER OF EMPLOYEES: �] C3SEPTICTANK TYPE/MFG , ICI _ CAPACITY _J gal #OFCOMPARTMENTS_,_o�.___ ❑ GREASE TRAP TYPE/MFG -� CAPACITY__- gal #OF COMPARTMENTS,_ DISTANCE TO NEAREST: WELL. 1t FOUNDATION-_ It PROPERTY LINE ft ❑ LIFT STATION SIZE _TYPE OF PUMP_ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS +^ #OF LINES 2 LENGTH OF LINES 170' ft DISTANCE TO NEAREST WELL it FOUNDATION 42O, It PROPERTY LINE __it ❑ FILTER BED WIDTH it LENGTH It DEPTH it DISTANCE TO NEAREST WELLit FOUNDATION____ft PROPERTY LINE it O MOUNDED WIDTH it LENGTH ft DEPTH �.. DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH it LENGTH _ _ft DEPTH,- it DISTANCE To NEAREST WELLit FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH _ _ ft LENGTH._._._........._.._..............._..._..._.._...... .ft DEPTH.---_...---.SAN,jQ/ ft. DISTANCETO NEAREST WELL_..__'_ft FOUNDATION ft PROPERTY LIQ C SEEPAGE PITS NUMBER WIDTH _____ _`M _____ft DEPTH,,,_�,- pI R-_- DISTANCE TO NEAREST WELL ON &o A ft PROPERTY LINE D it 1jQ__„ ft FOUNDATION 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 LAWS. MINIMUM at HOUR ADVANCE N TICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 9953-776971/ SIGNED TITLE C..v _ DATE ©-'_f —/tJ tj tt DEPA TME A.- L4 V Application Accepts _ .... __.—.._ Date_._ r�,rye Area Employee ID# Final Inspection By SPE IAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: _ Plt(Sump Soil Character: COMMENTS PE SC Received I CfieqkVAmount Permit' Coda INFO B ash Remitted --get., Service Re uest# Invoice# Permit ID# 42.07 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5117