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r 0 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 995', NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAP& JOB ADDRESS CITY/ZIP WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED IALTERNATIV5 REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM y DESTRUCTION 'I INSTALLATION WILL SERVE: I RESIDENCE I COMMERCIAL ! 3 OTHER CROSS STREET xA CAf�-(_ NUMBER OF EMPLOYEES: APN / CJ -020 [/ PARCEL SIZE OWNER NAMEf, j I/��5•eL.c� ❑ GREASE TRAP TYPE/MFG PHONE Z gal # OF COMPARTMENTS 6 ft FOUNDATION ft PROPERTY LINE ft OWNER ADDRESS �/ 1 b ❑ CITY/STATE/ZIP �+"r/QLiI�Z C/Q 7 .SSi� CONTRACTOR &–e.&'^/J11 EXPIRED If Y PO --/S 4."--vI �A'L S PHONE '7— ft FOUNDATION CONTRACTOR ADDRESS lr/ U �f "7t' 6/% CITY/STATE/ZIP ��i�jP GQ enl_J - 7 LICENSE LJI IC -42 I C-36 OTHER NUMBER 00! EXPIRATION DATE ft PROPERTY LINE ft WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED IALTERNATIV5 REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM y DESTRUCTION 'I INSTALLATION WILL SERVE: I RESIDENCE I COMMERCIAL Date OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Permit ID# NUMBER OF EMPLOYEES: _ SEPTIC TANK TYPE/MFG Oe% c CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY Z gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE _ _ TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES EXPIRED 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 LIMOUNDED WIDTH ft LENGTH ft DEPTH Pr- r)it Aa ft P&I J Y** E To NEAREST WELL ft FOUNDATION ft PROPELIi� J,I ft ❑ SUMPS_rxW H _ _ ft LENGTH Y" ft DEPTH ccI'XY`` ft 17ANCE 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 COMPENSATION LAWS. DATE / —7- / Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTSP'Uf//! Date Area 11 `7 - l Employee ID# F1 SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE Sc Received "h c, Amount Date Permit/ Invoice # Permit ID# Code INFO B Cash Remitted Service Request # Z CI 32�Z �Z. EXPIRED 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17