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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 NUN-NEFUNUABLE PERMIT GALL (ZU&Iy53-/b`J/ FOR INSPECTIONS tXPIRES 1 YEAR FROM UATE ISSUE. JOB ADDRESS %-,-VV V l � . ��NbZ NN � 'p CITY/ZIP IAl Jr✓� 1lS SJ CROSS STREET k L 1''' A P N V (/ ' -0PARCEL SIZE OWNER NAME OCi ham.( b t'& PHONE 2A -M-203,L- OWNER ADDRESS [>L2 � / /�/ !�/ \1 CITY/STATE/ZIP CONTRACTOR _ L a j�V 1k 04101 ��Y-- PHONE��',(�, )� ` /� /� G CONTRACTOR ADDRESSM72 bp:006" ��/�'� CITY/STATE/ZIP O- "' DZ5T CA LICENSE C-42 1-1 C-36 OTHER C_ y1 NUMBERef \ l EXPIRATION DATE, WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESI NED/ALTERNA VE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTIO INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL _ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS__ CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE _ ft 014 PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ltA ❑ LEACH LINES LEACHING CHAMBERS A� Ir #19F LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL i/N fION ft PROPERTY LINE ft ' L3 FILTER BED WIDTH ft LENGTH j� ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 ft 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 COMPENSAZ W LAWS. SIGNED � +� - TITLE JA,&),J DATE Application Accepted By Date (t// // /O Area Final Inspection By Date I SPE Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS Z2�� Employee ID# .Ae*_ ! ERMIT - Approved by PE Code C INFO Received B ec ash Amount Remitted Date Permit/ Service Request # mit ID# 2 7- lIV_jA='jj 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17