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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 (:ALL (2U.9,11.953-16.91 FOR INSPECTIONS LXPIRES I YEAR FROM DATE ISSUEI JOB ADDRESS I --> IS C, #14 -ANG h L Wn f LIS Q CITY/ZIPn.i.420_1V Y -S �2UV CROSS STREET+��1 �^►�Q 1 APN �r��o�� -- PARCEL SIZE OWNER NAME J� N©4 C_ 00 (1% C PHONE OWNER ADDRESS s 13q ` 1 C�t� FD_CITY/STATE/ZIP I IP61/ t CONTRACTOR S U �y NIL SeP 1 1 V PHONE �j � � 9 di o ce, V., C1 �/� + qS I CONTRACTOR ADDRESS 3 31 S S f Q Q)%w CITY/STATE/ZIP Tu'L64A LICENSE ❑ C-42 Ll_ C-36 OTHER h NUMBER)3 r/� � EXPIRATION DATE f q WATER TABLE DEPTH:I yy It GEOGRAPHICAL INFORMATION: Coordinates X Y L 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 U COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS� ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION 1,0 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 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 It 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. 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE SIGNED �(' �l �tl' _ TITLE-CIWh�gL DATE - H Z W i C- o<_ LLI 0 2 H DEPART-MENT USE ONLY ++,,y,�� Application Accepted By Date Z Area Employee ID#�iy Final Inspection By Date / ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ��LU� T�-ls� 9I!=Z,.I,2 PE Code SC INFO Received B Check#/ Amount ed Cash Remitted Date Permit/ erviceR# Service R Invoice # Permit ID# 7( ( I' yeuest SgVo-Ir 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T