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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 ! �� SC,I.,A4V4 f - CITY/ZIP !-7- f/� /J ' APN � 1 yCROSS STREET vOWNERNAME PHON&42I & /4 OWNER ADDRESS /f � ��ryG CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I I C-42 I C-36 OTHER NUMBER EXPIRATION DATE_ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIV REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION L INSTALLATION WILL SERVE: 19-PESIDENCE L i COMMERCIAL I . OTHER NUMBER OF LIVING UNITS: 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 ❑ F'KG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 E�Fn/ w ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 9 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIIIft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ^E�pN.,T=��N ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Ff EPARTA, 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 COMPENSAILON LAWS. MINIMUM WHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE_ DATE 1 �7 EPARTMENTUSE ONLY Application Accepted By ► Date I Area Employee ID# s�k-4r, Final Inspection By , Date bff 2. 1q CI SPECIAL PERMIT-Approved by Character of Soil to D ptq 3 Ft: _ Pit/Sump oil Character: COMMENTS C (0) *NA;.-:;V-61! I r PE SC Received CheckAmount Date PermiU Invoice# Permit ID# ode INFO B Remitted Service Re uest# 1-221 S Z l 2 /c pJ (ally 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17