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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 E;ALLLU`J `JbJ-/bJ/ FOR INSPECTIONS CXPIHE5 I T EAH CHUM LJA I t 155ut1 JOB ADDRESS ,U7y � N w �� I LA^j � �7i CITY/ZIP W0 CROSS STREET ` `�'f w �',�{ n APN -0 12 I Oy 16 PARCEL SIZE Ze , 1 �S OWNER NAME –Sw %I ` `"Y PHONE OWNER ADDRESS SAMS- AS 55WIL CITY/STATE/ZIP CONTRACTOR \N ES t L-:) AS 7 "J A 0--4 NA,) 1 N C PHONE ) CONTRACTOR ADDRESS 33 P A X%,j 6) 1 J L 0';a I- CITY/S- ATE21P'�.��Z-1� 3 7 LICENSE I I iC-42 I I iC-36 OTHER NUMBER 1) EXPIRATION DATE —0 7 WATER TABLE DEPTH: _ 7a ft GEOGRAPHICAL INFORMATION: Coordinates X Y IJ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I I DESTRUCTION INSTALLATION WILL SERVE: I I RESIDENCE ❑ COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY It FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES I) LEACHING CHAMBERS I,,, f1 % tr ffw # OF LINES LENGTH OF LINES y ur ft DISTANCE TO NEAREST WELL 100 ft FOUNDATION I ft PROPERTY LINE �-� ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH RCw DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ,1 ❑ SUMPS WIDTH ft LENGTH ft DEPTH FIA n DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE'tt L3 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTHmzzQ(/ `fI DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE )Qo SEEPAGE PITS NUMBER Z WIDTH 3 6 ft DEPTH -7,5 DISTANCE TO NEAREST WELL_ ft FOUNDATION ZO ft PROPERTY LINE I JJ 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 48 HOUR ADVANCE ED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED �� TITLE 1'' / (-� � ✓ `- DATE T b L -) DEPARTMENT USE ONLY r // Application Accepted By Date / 7Area. Employee ID# Final Inspection By r Date 31Ll SPECIAL PERMIT - Approved by Character of Soil to Depth o 3 Ft: Pit/Sump Soil Character: COMMENTS 01-54 i,eiYvlaht"er L J', byK I 10 C5' nlr4l in PE Code SC INFO Received B eCfiecykV sh Amount Remitted D to Permit/ Service Re uest # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17