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Sn edONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN C NTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 19ISR a 1:1110LJ:l:i&III FOR INSPECTIONS tXPIRES 1 YEAR FROM UATE ISSUE JOB ADDRESS /CV�/� / / / �� U CITY/ZIP /'610.1 f (J�' r ., CROSS STREET Y � iS r APN [ �0 7 PARCELSIZE OWNER NAME: P64f, _er 2Q PHONew/v' I OWNER ADDRESS 1,716 �e._ CITY/STATE//ZIP !�'�r I L/:, tO CONTRACTOR filk `�� PHONE CONTRACTOR ADDRESS C CITY/STATE/ZIP LICENSE ❑ C-42 ❑❑C-36 OTHER_ NUMBER N4PSS3_EXPIRATION DATE / —31' WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y ❑ PERC TEST # BUILDING PERMIT #_____ __ LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION LI REPAIRIADDITION ENGINEER DESIG D/ALT@RNATIVE ❑ REPLACEMENT 11 OUT -OF -SERVICE SEPTIC SYSTEM iNl DESTRUCTION d( INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL A OTHER NUMBER OF LIVING UNITS: — NUMBER OF BEDROOMS: __ NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY _ gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY _ 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 F -I 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 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 COMPENSATION LAWS. MINI UM 4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 TITLE f� DATEA14N SIGNED 1+ _ AL OtN ON kL E VlM, AOM d T DEPARTMENT USE QNLY Application Accepted By Date Area Employee ID# Final Inspection By .i Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: USump Soil Character: COMMENTS e PE Code SC INFO Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 4 v7 7� 11 ZZ -V I I6 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17