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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 IVUN-KEFUNDAe1-E1E/PERMIT DISTANCE TO NEAREST L ALL (ZO9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS l -7 ya,4 Jn5)�'- 'i CITY/ZIP <f(ll',:; CROSS STREET CiAf h—t r APN Zd�j� 1 D ( PARCEL SIZE O �J OWNER NAMEX��1uV6� WIDTH ft PHONES OWNER ADDRESS 154-7b WIDTH V dI/ z, CITY/STATE/ZIP CONTRACTOR IM, S ft �� PHONE � SIG ` )9(057i CONTRACTOR ADDRESS b j 6,--& 6,--& r q c �i CITY/STATE/ZIP II�"��%¢ I C( 3 LICENSE ❑ CC -42 ❑ I C-36 OTHER �� NUMBER EXPIRATION DATE IB WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y IJ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION , ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT Ll OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION ' S I llyCy TL/Q,W INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: y. I NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG ;; Ai( I r �'�ir CAPACITY 1600 00 gal # OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS a DISTANCE TO NEAREST: WELL � ft FOUNDATION S ft PROPERTY LINE 10 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES WELL DISTANCE TO NEAREST FILTER BED WIDTH ft DISTANCE TO NEAREST MOUNDED WIDTH WELL DISTANCE TO NEAREST SUMPS WIDTH ft DISTANCE TO NEAREST DISPOSAL PONDS WIDTH WELL DISTANCE TO NEAREST SEEPAGE PITS NUMBER ft DISTANCE TO NEAREST # OF LINES WELL SC INFO It FOUNDATION ft LENGTH Invoice # Permit ID# WELL I.S� It FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION WIDTH WELL ft FOUNDATION ft ft ft ft LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LI V DEPTH ft PROPERTY LII' DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL SIGNED TITLE r�ii DA' Application Accepted Final Inspection By� Character of Soil to D COMMENTS of 3 Ft: ft ft ft ft ft ft ft ft M DEPARTMENTUS ONLY Date ? Area Employee ID#� Date Sr11 ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE Code SC INFO Received Check#/ Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 4 24 c7 I.S� —L9 (e9 S 1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 V_.