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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 191 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 ISSUE JOB ADDRESS CITY/ZIP I p • ) �r� !ROSS STREET �� LEw%�i7�1> APN A91-62' (/ _ PARCEL SIZE OWNERNAME •�� % �l ♦' (K_ `� l� z _ _. _ PHONE OWNER ADDRESS � & CITY/STATE/ZIP !� ✓ �/ ✓�` CONTRACTOR /( l /�i 99��i �� i/�y XsG ' _ PHONE CONTRACTOR ADDRESS '/� Gf�Y fLb CITY/STATE/ZIP LICENSE � I IC -42 ❑ IC -36 OTHER NUMBER ��. EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ENGINEER DESK 1 REPLACEMENT LJ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION _ D /ALTERNATIVE INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 21 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT D gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) SIGNED Application Accepted By !� Final Inspection By� Character of Soil to Depth of 3 Ft: COMMENTS Z TIRED FOR INSPECTIONS - TITLE4: f 4 DATE �- -- DEPARTMEN US LY Date. Area Employee ID# Date 2 % ❑ SPECIAL PERMIT - Alf rove by Pit/Sump Soil Character: Sar,��/ �s, PE Coders LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES C� / ft Amount Remitted DISTANCE TO NEAREST WELL / / PP� ft FOUNDATION �ft PROPERTY LINE j 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 fj FOUNDATION ft PROPJERTTYLINE ft SUMPS WIDTH ✓`�' J ft LENGTH / / ft DEPTH /z' 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 WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 COMPENSATION LAWS. SIGNED Application Accepted By !� Final Inspection By� Character of Soil to Depth of 3 Ft: COMMENTS Z TIRED FOR INSPECTIONS - TITLE4: f 4 DATE �- -- DEPARTMEN US LY Date. Area Employee ID# Date 2 % ❑ SPECIAL PERMIT - Alf rove by Pit/Sump Soil Character: Sar,��/ �s, PE Coders SC INFO Received ec s Amount Remitted J to Permit/ Service Request # Invoice # Permit ID# V 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17