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ONSITE WASTEWATER TAEATMENT SYSTEM PERMIT P✓If SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDA LE PEF,' IT 4 CALL (209 9`3 -76971=01 -LN_ SPECTIONS _ EX IRES 1EA FR fA DATE ISSUED JOB ADDRESS z __- _ -_ _ CITY/ZIP �__ CROSS STREE' C ■ `, APN �_� �_ ��y v -___ PARCEL SIZE OWNER NAME V n • ✓ '` �� _L _ - . _ _ PHONE OWNER _� % `� �� OWNER ADDRESS I—P xNt/`_! lz__ CITY/STATE21P I..�+�i 0 ( ��2- q -v CONTRACTOR 'K1 f-' ' `�' �� { MIS C PHONE �i O - C) 6 t� CONTRACTOR ADDRESS 4 ' w� _ _ -_ _CITY/STATE/ZIP yRxu 0- 5 2P. -S LICENSE C-42 11:_iC-36 OTHER NUMBER - \ t_ _ EXPIRATION DATE_ `l 1 WATER TABLE DEPTH: U It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # I BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE I I COMMERCIAL I I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ` _i5ACrrY gal # OF COMPARTMENTS__ ❑ GREASE TRAP TYPE/MFG _ _ _ _ CAPACi rY 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) LEACH LINES �(� LEACHING CHAMBERS._- _- # OF LIMES LENGTH OF LINES ft Ile, DISTANCE TO NEAREST WELL FOUNDATION 40 It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ____ ft DEPTH ft DISTANCE ToNEAREST WELL ft FOUNDA1ION _ ft PROPERTY LINE ft ❑ MOUNDED WIDTH __— It LENGTH _ _ ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft �4- — - -- r SUMPS ( WIDTH ft LE TH ft � DEPTH ft DISTANCE TO NEAREST WELL 1200' _ ft FOUNDA MON , ft PROPERTY LINEft ❑ DISPOSAL PONDS WIDTH _ ft LENGTH ft DEPTH lipf%L.I. ft '11114;1 VQ DISTANCE TO NEAREST WELL _ _ _ ft FOLJNDATION _ ft PROPERTY LINE a ft L3SEEPAGE PITS NUMBER WIDTH - _ _ _- --ft DEPTH PAY /. n ft GY�I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY "'w ft 11V C; I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACa WRA ; JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQQCis. CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT WORKERS COMPENSATION LAWS. 24 O"!M ICE REQUIRED FOR I 0W I WfASE CALL 209 03-V94 SIGNED � - _, TITLE- _ DATE - Application Accepted By _ Final Inspection By Character of Soil two Depth COMMENTS Ft: Date Date - Pit/Sun 7�M'/ Area SPEC Soil Character: Employee ID#� - Approved by PE Code SC INFO Received BV hec ash Amount D e Permit/ emitted Service Request Invoice # Permit ID# c7 � HOW 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17