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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 .JOB ADDRESS 953-7697 FOR INSPECTIONS CITY/ZIP IRES l YEAR FROM DATE ISSUEI WATER TABLE DEPTH: GU I /% U ft ow - GEOGRAPHICAL INFORMATION: Coordinates X IJ PERC TEST # CUILDING PERMIT # TYPE OF WORK: i NEW INSTALLATION REPLACEMENT INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: LAND USE APPLICATION # REPAIR/ADDITION OUT -OF -SERVICE SEPTIC SYSTEM ❑ COMMERCIAL NUMBER OF BEDROOMS: SEPTIC TANK TYPE/MFGL-- ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ft ❑ LIFT STATION SIZE TYPE OF PUMP Y ENGINEER DESI EI DESTRUCTION ❑ OTHER NUMBER OF EMPLOYEES: CAPACITY_ gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS FOUNDATION _ ft PROPERTY LINE ' — -4 ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) / , SC INFO LEACH LINES LEACHING CHAMBERS CROSS STREET / APNIff /v ' (/ PARCEL SIZE WELL ft ,v l FOUNDATION ft PROPERTY LINE Vi ft ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH It OWNER NAME L -[.T PHONE�//��i�.��'' FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH Lam! i.�Y &AD DISTANCE TO NEAREST WELL ft OWNER ADDRESS Z —CITY/STATE/ZIP _ ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN JO ft El DISPOSAL PONDS WIDTH CONTRACTOR /_��' / i�G L PHONE DISTANCE TO NEAREST WELL? FOUNDATION ft PROPERTY LIN RTM¢ — ft /V'/�✓�j WIDTH N ft DEPTH Z S� ft CONTRACTOR ADDRESS /�' %Nl/ CITY/STATE/ZIP � FOUNDATIONft PROPERTY LINEsyr�' ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN LICENSE C-42 ❑' IC -36 OTHER-04NUMBER ?EXPIRATION DATE WORKERS COMPENSATION LAWS. ` / 1 WATER TABLE DEPTH: GU I /% U ft ow - GEOGRAPHICAL INFORMATION: Coordinates X IJ PERC TEST # CUILDING PERMIT # TYPE OF WORK: i NEW INSTALLATION REPLACEMENT INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: LAND USE APPLICATION # REPAIR/ADDITION OUT -OF -SERVICE SEPTIC SYSTEM ❑ COMMERCIAL NUMBER OF BEDROOMS: SEPTIC TANK TYPE/MFGL-- ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ft ❑ LIFT STATION SIZE TYPE OF PUMP Y ENGINEER DESI EI DESTRUCTION ❑ OTHER NUMBER OF EMPLOYEES: CAPACITY_ gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS FOUNDATION _ ft PROPERTY LINE ' — -4 ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) MI UM 24 HOUPADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED 14 4i�lklv TITLE__y DATE z DEPARTMENIT USfir0&LY App!ication Accepted By Date Area _ Employee ID# V Final Inspection By Dat J, ZAO ❑ SPECIAL PERMIT - Approved by kv-Character of Soil to Depth 0 F : Pit/Sump Soil Character: _ Cl�'✓COMMENTS � � � � J+� PE SC INFO LEACH LINES LEACHING CHAMBERS eck s # OF LINES :2!!2e LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft ,v l FOUNDATION ft PROPERTY LINE Vi ft ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTHft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE IA ft ❑ SUMPS WIDTH _ ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN JO ft El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH H�LT7/RONM� COU ft DISTANCE TO NEAREST WELL? FOUNDATION ft PROPERTY LIN RTM¢ — ft SEEPAGE PITS NUMBER WIDTH N ft DEPTH Z S� ft c DISTANCE TO NEAREST WELL-/ ft � FOUNDATIONft PROPERTY LINEsyr�' 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. MI UM 24 HOUPADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED 14 4i�lklv TITLE__y DATE z DEPARTMENIT USfir0&LY App!ication Accepted By Date Area _ Employee ID# V Final Inspection By Dat J, ZAO ❑ SPECIAL PERMIT - Approved by kv-Character of Soil to Depth 0 F : Pit/Sump Soil Character: _ Cl�'✓COMMENTS � � � � J+� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 PE SC INFO Received By, eck s Amount emi ted Date Permit/Code Service Request # Invoice # Permit ID# 0 / 22 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17