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r; ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT n/. CALL (209) 9537697 FOR INSPECTIONS - EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS r F , CITfY/ZIP�j?ff0r*1j CROSS STREET i V w /) , APN��V / _ PARCEL SIZE OWNER NAME � /^e/c k Paw, 5 6 �C L.e r NONE OWNER ADDRESS f!V �Q i[ 7 O CITY/STATE/ZIP CONTRACTOR �/'/!/`' 1/ _ PHONE CONTRACTOR ADDRESS LICENSE ❑ C-42 ❑ C-36 OTHER CITY/STATE/ZIP UMBER EXPIRATION WATER TABLE DEPTH: I )n&Vi WV ft GEOGRAPHICAL INFORMATION: Coordinates X Y IJ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNAT Re 't ed Service Request # X REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION I t INSTALLATION WILL SERVE: RESIDENCE I.1 COMMERCIAL ❑ OTHER V' S 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 r _ _ It FOUNDATION _� y _ ft PROPERTY LINE I od ( ft LIFT STATION SIZE 0 TYPE 14 OF PUMP __ KG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTH R x — It LENGTH • S ft DEPTH 0„ ft i, 8fl3 DISTANCE TO NEAREST WELL,/!b�' ft FOUNDATION if 0 ft PROPERTY LINE ft ❑ MOUNDED �1,�y WIDTH __ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It 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. L (209) 953-7697 GG ©A DATE jAd ++-H AJ r- � � 030 SIGNED Application Accepted By Final Inspection By Character of Soil topep? COMMENTS RED FOR INSPECTIONS - PLEASE CAL TITLE O Cts N e✓ T 4?EPARTMENT175E10NXY /%/� Date Area t� L�I Employee ID# Date_ g ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: all PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO By Cash Re 't ed Service Request # V' S r� I I W7%2_5 os S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17