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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN 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 LATE ISSUEI / JOB ADDRESS �GN /� ^ L CROSS STREET Mk J U'd ji;�C 'r r- 7 �L APN XS -3- 110 o " a PARCEL SIZE ' OWNER NAME ✓Y► .0-rx/d%�T*�%fj11L, /T� /� �DPHONE OWNER ADDRESS ,? 4/ ' �6 / 4 V 1� ( _CITY/STATE/ZIP CONTRACTOR Y I` dzeai4 =I� �w PHONE CONTRACTOR ADDRESS Pn 13, S,1 CITY/STATE/ZIP LICENSE ❑ C-42 ❑ _ C-36 OTHER NUMBER D.iJ" EXPIRATION DATE an 1 WATER TABLE DEPTH: 11 O ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # do TYPE OF WORK: i NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG L CAPACITY gal # OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS } DISTANCE TO NEAREST: WELL :')*+0 It FOUNDATION —ft PROPERTY LINE too ft ❑ LIFT STATION SIZE TYPE OF PUMP C3PKG TX PLANT LISAND OIL SEPARATOR (ENCLOSED SYSTEM) 9 --'LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES; s?f ft DISTANCE TO NEAREST WELL j� It FOUNDATION its, ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft W-/ SUMPS WIDTH �)_ ft LENGTH IeR I ` ft DEPTH LjI ft DISTANCE TO NEAREST WELL. `S} It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH __ It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE f1 ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL It 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. MINIMUM 24 HOV DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED _ TITLE_ 3W r-�'DATE I-4 1. C• 1-7 Application Accepted B Final Inspection By & Character of Soil to Depth of 3 COMMENTS TME.NT IJ S E ": L Y Date Area 4 Employee ID#� Date Z6l ❑ SPECIAL W_ Date -Approved by Pit/Sump Soil Character: SQrU Y v v ra PE SC Received hec Amount Date Permit/ Invoice # Permit ID# Code INFO B RemittedService Re uest # Z D �__ �v . ..- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17