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ONSITE WASTEWATEI'l SYSTEM PERMIT SAN JOACAJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUF - STOCKTON CA 95205 - (209) 468-3420 NON. -REFUNDABLE PERMIT n//� CALL 20/9) 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS _07-1 j VA (/ /,/Ay_ CITY/ZIP i CROSS STREET APN/_ '[� PARCEL SIZEf� % % Cl OWNERNAME PHONEi /8I -8u / OWNER ADDRESS , Com/ CITY/STATE/ZIP CONTRACTORv '_ _ -' e'T PHONE CONTRACTOR ADDRESS EXPIRED E CITY/STATE/ZIP LICENSE C-42 I C-36 OTHER NUMBER ExPIRATION DATE_ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y PERC TEST # [—BUILDING PERMIT # _ Qzkg LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIWADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION LATION WILL SERVE: %msRESIDENCE ❑ COMMERCIAL OTHER n UMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: _ ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE ToNEAREST: WELL ' _kIt FOUNDATION__- � It PROPERTY LINE �� / It 1y LIFT STATION SIZE�Z dlr,� OL -TYPE OF PUMP " ❑ PKG TX PLANT L3 SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS _ _ — # OF LINES _ LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH _ 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 —_ PERM ft DEPTH ft DISTANCE TO NEAREST WELL �t� -OOND/f ON ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH _ ft LENGTH _ _ XX _____ft DEPTH _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER--------- WIDTH—_- -_ It DEPTH tt 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 LAWS. F- NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED / TITLE _6CAA1-'C4& _--__ _ DATE D^EPARTMENT USE O�N1LY Application Accepted By L'L�IC Date ---I t' J Area _ L �G - Final Inspection By Date_ CI SPECIAL PERMIT Character of Soil to Depth of 3 Ft: TF Pit/Sump Soil Character: COMMENTS Lj\ k J ic�n ar a Gii 4 i y n - — ----- - PE SC Received hec Code INFO Bv ash 42-01 5/5/17 Employee ID# Approved by Amount Date Permit/ Invoic# Permit ID# Remitted -, Ser ice Request # ONSITE WASTEWATER TRTMNT SYSTEM PERMIT