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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 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS b(a N N uj c;I, CITY/ZIP rlj rN J CROSS STREET PARCEL SIZE OR- > OWNER NAME PHONE f' � OWNER ADDRESS J��.t}A� lY1'y CrrY/STATE21P /� �j CONTRACTOR �l+J 1 C� �1p f (�� 'nG• PHONE _(Z" 9)' 3 i 7y39� (�]� CONTRACTOR ADDRESS 33,m r"A I V 1 CrrY/STATE21P W(N� C71 �� 1 V Q LICENSE ❑`.IC-42 ❑nC+t36 OTHER NUMBER 3511 Sl EXPIRATION DATE O J WATER TABLE DEPTH: a O It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑/, NEW INSTALLATION �,I REPAIR/ADDrnON n ENGINEER DESIGNED/ALTERNATIVE 'd REPLACEMENT lel-'Ch Cie�•^ ❑ OUT-OF-SERVICE SEPTIC SYSTEM U DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL P F' PG 11? [J_ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL It 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 LENGTH OF LINES It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINF, ft FILTER BED WIDTH 40 It LENGTH 7,50 ft DEPTH •I W a ft DISTANCE TO NEAREST WELL N�J I/-V ft FOUNDATION + 3-- ft PROPERTY LINE S� ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it ❑ SUMPS WIDTH ft LENGTH ft DEPTH PA I,. ft DISTANCE TO NEAREST WELL It FOUNDATION ft .PROPERTY LINE T ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH I DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI MWITHL I HEREBYCERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACC � UNJOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRE L CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCEEN WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED CLQ TITLE DATE -7 IF)irlo J IF l p DEPARTMENT USE ONLY Application Accepted y G_ Date / ?Ovii7 Area 9q Employee ID# DA Final Inspection By Date 44�, 120 ❑ SPECIAL PERMIT-Approved by Character oiSoil to Depth of 3 Ft: Pit/SUmp Soil Character: COMMENTS Fe lu°e o{ SY54crn ��n_p�lbi�c rrc: e'• S{ tl�+n4 Irt';�t►�;� QCT /n<x/rhu,>n 6f 0:,e between fhc•r✓16F1S rant! ch�mbr�rynG�slG�f-wc,l� sh.l1 be mc�InEc�+hPl PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# tia)a 05- C �3a� �f is to S Oo�Z32�- 42-01 � 5J 0133_3 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118 �J