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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS G�- /T / CITY/ZIP CROSS STREET �/ /�%VU✓ APN �[Q _ PARCEL SIZE OWNER NAME �% nn __ PHONE OWNER ADDRESS / U 'Dliy Y ___ ___ ____ CITY/STATE/ZIP _ qLZ� CONTRACTOR PHONE�T��1 CONTRACTOR ADDRESS I %'L�//'�%, CITY/STATE/ZIP 7�W� i LICENSE! C-42 U !C-36 OTHER NUMBER ��-7� EXPIRATION DATE WATER TABLE DEPTH: Il O l W 1 It GEOGRAPHICAL INFORMATION: COOT inates X _ Y ❑ PERC TEST # BUILDING PERMIT #Fir .- LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION PAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: It RESIDENCE Ll COMMERCIAL LI OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY !�OOI> gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL —f — It FOUNDATION ft PROPERTY LINE -,/V It— ❑ LIFT STATION SIZE TYPE OF PUMP _ -L] ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES '3 LENGTH OF LINES 460 l It DISTANCE TO NEAREST WELL ft FOUNDATION �/Z� It PROPERTY LINE , ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH it 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 it ❑ SUMPS WIDTH _ It LENGTH it DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE It SEEPAGE PITS NUMBER b WIDTH ft DEPTH — S+ It DISTANCE TO NEAREST WFLL !o.�� ft }} ) FOUNDATION 4> 14 ft PROPERTY LINE It 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. UuIVIIVICIV 1 O PE ode SC INFO Received B Check#/ Amount Cash Remitte Date Permit/ Service Request # Invoice # Permit ID# 7i 10 rj � bbl+ 0If� 42-01 -7 �� Sg2 � ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T