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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 PER MIT (:ALL ZUy Jb3-/65/ FOR INSPECTIONS t_XPIRES► 1 YEAR FROM UAT JOB ADDRESS 15475-5, Or _ CITYIZIP ��C�� i/ CROSS STREET Sam (� APN "' Q, -3 ® )-0 13 PARCEL SIZE O' v - / OWNER NAME 1 [NLI 1. 5I1 S (► n (PHONE OWNER ADDRESS U L (� CITY/STATE/ZIP W -0 95911 / • CONTRACTOR PHONE a O9 -� _ s�a7 I ``fel � C[' Q CONTRACTOR ADDRESS 'P.+ l (t 4/'� Son b". f��p �[� CITY/STATE/ZIP LICENSE 1 IXC -42 1 1 C-36 OTHER NUMBER Iy ! : T' EXPIRATION DATE /\ I - I WATER TABLE DEPTH: v ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # 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 1_1 COMMERCIAL ? ❑ OTHER NUMBER OF LIVING UNITS: ' NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG ��Tr't`I CAPACITY TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION SIZE TYPE OF PUMP ❑ PKG TX PLANT F gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS ' # OF LINES �I LENGTH OF LINES 440 ft DISTANCE TO NEAREST WELL O6 ft FOUNDATION �©©ft PROPERTY LINE 310 ' 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 3 WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 36 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 COMPEN ATION LAWS. MINIMUMgHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE �N_ �t. G r DATE a — / SIR . Application Accepted Final Inspection By YIN Character of Soil to Depth o COMMENTS DEPARTMENT USE ONLY � 1 rig Date_ �) Area Date 1 ❑ SPECIAL PERMIT Pit/Sump Soil Character: Employee ID# �` 7 Approved by PE SC Receive Check#/ Amount Permit/ Code INFO By Cash Remitted Date Service Request # Invoice # Permit ID# 1).5- 2 3a, You 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17