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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SgN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUND4p,6g PZRWl�ja>� _ CAL 2q9) 9J3-7697 FOR INSPECTI E4PIBES 1 Y TE ISSUED JOB ADDRESSTlu LAW&CITY/ZIP ULUA 0 tY 1 f t CROSS STREET OWNER NAME OWNER ADDRESS 1 U04- CONTRACTOR CONTRACTOR ADDRESS qVa� LICENSE C-42 F1 C-36 OTHER APNI �6. Cne�vo�nc� NUMBER _ PHONE CITY/STAT IPQ. / "0 1 CITY/STATE/ZIP � Urn_, CEXPIRATION DATE PARCEL SIZE % " rl i+� /SZ— WATER TABLE DEPTH: �(/ it GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE Tx REPLACEMENT DESTRUCTION �.[✓1 INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 1. OTHER NUMBER OF LIVING UNITS: I — NUMBER OF BEDROOMS: 4 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG r 1 CAPACITY MU(gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ft C1 n / 4 ` DISTANCE TO NEAREST WELL __ ft FOUNDATION DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP _ . ❑ PKG TX PLANT O SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES Y LEACHING CHAMBERS _ # OF LINES LENGTH OF LINES ft • ! Date 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 LJ MUUNUEU WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL _ _ ft FOUNDATION ft PROPERTY LINE DEPTH ft ft SUMPS WIDTH _- ft L ! N DISTANCE TO NEAREST WEL.---ft--FOUNDATION ft PROPERTY LINE 5 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH It 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 WORKE5�COMPENSATION LAWS. iMZW9124 I;OUR"VAA1G&JMimTJCELREQUIRED FOR W Pi°!r✓M' NS 4kEASE CALL (209) 953476971 SIGNE 0 TITLE 0 DATE ?7 DEPARTMENT USE ONLY L/ / `l� Application Accepted / / Date Area Employee ID# (,(/ Final Inspection By Date7,110d ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: it/S mp goil Character: COMMENTS T: f r -ffLUu) i n : Irjl:ori PE Code SC INFO Received B Check#/ Cash Amount Remitted Date PermiU Service Request # Invoice # Permit ID# A S 6 a0 its 6o76Li1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r�