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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 I4UN-11EFUNDABLE VERMIl s (:ALL (709) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROKDATE ISSUEI JOB ADDRESS� 1 2 / 15 .ay_[CITY/ZIP � lrY CROSS STREETM /r,/ 1 ( I"� -/ V ,J� �JC�� ] / APIN Zz / PARCEL SIZE OWNER NAME) r �MjITC11/ ��'V� PHONE OWNER ADDRESS •l� 1 "' C,G�O�63„/� � CITY/STATE/ZIP �- �A CONTRACTOR _ t �C -� ��c K h s� ��Z PHONE �'I`�`y L �LS CONTRACTOR ADDRESS r (�S`0 CITY/STATE/ZIP 1Y-,re/r 44 - LICENSE I I C-42 I I C-36 OTHER • 1 NUMBER) EXPIRATION DATE (, I WATER TABLE DEPTH:ZP ft GEOGRAPHICAL INFORMATION: Coordinates X Y L PERC TEST # BUILDING PERMIT #_00_ LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE:]ESIDENCE L COMMERCIAL L' OTHER NUMBER OF LIVING UNITS: 1 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) _ . _-----.. __ _. __ _ _.. ________ ACH LINES LEACHING CHAMBERS � _... __. ____ _ ____..___._____ . __ _. ___ __11 __._ _._ ____—..__.. I. Q-0 # OF LINES .� LENGTH OF LINES ft DISTANCE TO NEAREST WELL _ ft 9 FOUNDATION 16 ft PROPERTY LINE Al 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 COMPENt�S�J ION LAWS. MINIMUM! DVANCE NOTICE REQUIRED FOR INSPECTIONS CALL 209 953-7697 , `PLEASE C-t�I r SIGNED _ TITLE r��-t7 z7 i DATE V: Y �kDEPARTMENV.T SE O Y Application Accepted y Date Area � Employee ID#� Final Inspection By _ Date SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: PiUSump Soil Character: COMMENTS :ff, , (AVQ jLj7UV9,J PE Code SC INFO Received B Check#/ Cash Amount emitted Date Permit/ Service Request # Invoice # Permit ID# n ? 3 fflf SJ20t) 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17