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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-REFUNDABLEPERMITCALL Sc INFO 209 953-7697 FOR INSPECTIONS 1 YEARFROM DATE ISSUED JOB ADDRESS �'l�V pN� CROSS STREET �.rTf-Y/_4!41 670L�� &�� /��l,l�{ExP�IRES CITY/ZIP 9!3 - S ft FOUNDATION �j��VVF/'�/y / APN I'f / l UyJ PARCEL SIZE OWNER NAME /VKkl I V HDLINA _57 :L T OWNER ADDRESS qq IYA/ztly D/ APHONE d/J CITY/STATE/ZIP N/JH�N/G(� /7 /`/1 / y ?40 J CONTRACTOR Saf" - tf?yay *6 PHONE U V DISTANCE TO NEAREST WELL CONTRACTOR ADDRESS dg 2 Mg-mv S7 CITY TE/ZIP ❑ SUMPS WIDTH ft LENGTH LICENSE C-42 C-36 OTHER NUMBER _--tjj-1 XV t4kRA`hON DATE WATER TABLE DEPTH: ft GEOGRAPHICAL I ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPLACEMENT INSTALLATION WILL SERVE: ❑ RESIDENCE NUMBER OF LIVING UNITS: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG X LAND USE APPLICATION # REPAIR/ADDITION / ENGINEER DE'. OUT -OF -SERVICE SEPTIC SYSTEM Y DESTRUCTION COMMERCIAL NUMBER OF BEDROOMS: CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT Y OTHER NUMBER OF EMPLOYEES: /AL gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Sc INFO Received # OF LINES DISTANCE TO NEAREST WELL Date ft FOUNDATION ❑ FILTER BED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH ft LENGTH ft DISTANCE To NEAREST WELL ft FOUNDATION ❑ DISPOL ft LENGTH _. ft O NEAREST WELL ❑ SEEJ"I WIDTH 1VIREIVINEAREST ft FOUNDATION WELL ft FOUNDATION LENGTH OF LINES ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH S� JOAQtltnr..,..._ ft ft PROPERTY I xI I NMENT ft DEPTH tt-ARTUENT ft 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 LAWS. MINIMUM 48QURADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953 - SIGNED TITLE -S.--�-WJ_F -0(6!lW DATE Application Accepted Byi Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS EPARTM Date Date E N Y Area ( Employee ID#SH=Y 1 SPECIAL PERMIT -Approved by Pit/Sump Soil Character: PE Code Sc INFO Received Check#/ Cash Amount emitted Date Permit/ Service Request # InID# fit: Mff 42-01 ONSITE ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17