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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-REFUN FINIVr CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM ATE ISSUEC JOB ADDRESS CII�T.�YY21P _ r �% CROSS STREET ! APN _.LZ PARCEL SIZE • , <.J OWNER NAME--� PHONE 9.36 OWNER ADDRESS _____ __---CITY/STATE/ZIP CONTRACTOR U /, A Pkfts k 4-ls PHONE "6 -7060 CONTRACTOR ADDRESS � {�-=�`�/ia/- 1t `� � CITY/STATE/ZIP- ' l LICENSE' 'C-42 ❑ I C-36 OTHER NUMBER -_-_ - _ EXPIRATION DATE7rs— WATER TABLE DEPTH: 1 D ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # _ _ LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATREPAIRIADDITION ENGINEER DESIGNED /ALTERNATIVE ON REPLACEMENT5-pp!OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE I l COMMERCIAL I OTHER Rrzalzil NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ 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 gal # OF COMPANI�FAi [u11— ❑ SAND OIL SEPARATOR (ENCLOSE'914TEM) 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 TI Application Accepted By Final Inspection By Character of Soil to D th MMENTS 13,1101, L 209 DATE i w T I I .I l i 1_L_ I I I I DEPARTMENT U E QNLY Date Area-� Employee ID# Xkkt I Date W41 ❑ SPECIAL PERMIT - proved by g� ►sr► _ Pit/Sump Soil Character: c--' A A rT1n '/-i • MD 14 lw fA/'n / AH l%t-iliitlz,1 !J- 1 �Z IML PE SC Received (–Cli Amount Date Permit/ Invoice # I;' t Code INFO LEACH LINES LEACHING CHAMBERS G50 # OF LINES LENGTH OF LINES It !� I I C + DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL it 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 _ It FOUNDATION --ft PROPERTY LINE ft SEEPAGE PITS NUMBER WIDTH ft DEPTH ft i T -- DISTANCE TO NEAREST WELL 1 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 TI Application Accepted By Final Inspection By Character of Soil to D th MMENTS 13,1101, L 209 DATE i w T I I .I l i 1_L_ I I I I DEPARTMENT U E QNLY Date Area-� Employee ID# Xkkt I Date W41 ❑ SPECIAL PERMIT - proved by g� ►sr► _ Pit/Sump Soil Character: c--' A A rT1n '/-i • MD 14 lw fA/'n / AH l%t-iliitlz,1 !J- 1 �Z IML PE SC Received (–Cli Amount Date Permit/ Invoice # Permit ID# Code INFO B as Remitted Service Request # 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17