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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 NOW -REFUNDABLE PERMIT GALL 709 953.7697 FOR INSPECTIONS ttXPIRES 1 YEAR FROM L)AT ISSUEI • JOB ADDRESS I yl CITY/ZIP Date �/✓ ! h� �� LINES CROSS STREET �.I,VQS �1 luJ / APN /7.?,- PARCEL SIZE OWNER NAME �GCV v �%ii Z�S _ _ _ _ _ _ _ PHONE z/1 3' �f Oe;'Oo-- OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR '{�LI C PHONE a��c� S�a / CONTRACTOR ADDRESS CITY/STATE/ZIP LOZ/i �( LICENSE Ll' -42 F- !C-36 OTHER meq. NUMBERJL� 10 571EXPIRATION DATE 1' 3L) ft PROPERTY LINE 'pLo ft � WATER TABLE DEPTH:f �� ift GEOGRAPHICAL INFORMATION: Cl PERC TEST # BUILDING PERMIT # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADC Coordinates X _ Y LAND USE APPLICATION #— )N i ENGINEER DESII 1 REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION _ D /ALTERNATIVE INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL OTHER NUMBER OF LIVING UNITS:rr NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG "S�7'j CAPACITY ❑ GREASE TRAP TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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 De t COMMENTS 1fZ ANCE NOTICE vn 11vCPrrca.11Wwo - rl-CIIOLC IiMLL rLV.7/DJJ-/V.7/ TITLE L1 ✓4i4DATE XU'�DIEIPARTMENTUSf ONLY Date ( Area -_ Employee ID#� Date 4 _ . F -I SPECIAL PERMIT - Approved by Pit/Sump Soil Character: -__ -- - - PE SC INFO Received B Check#/ Cash Amount Remitted Date Permit/Code Service Re uest # Invoice # xLEACH LINES LEACHING CHAMBERS # OF LINES Al LENGTH OF LINES T0.0 ft ��' i DISTANCE TO NEAREST WELL_ _ ft FOUNDATION ft PROPERTY LINE 'pLo 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 TTo NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I SUMPS WIDTH TZ ft LENGTH I ft DEPTH ft DISTANCE TO NEAREST WELL -5'0' 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 De t COMMENTS 1fZ ANCE NOTICE vn 11vCPrrca.11Wwo - rl-CIIOLC IiMLL rLV.7/DJJ-/V.7/ TITLE L1 ✓4i4DATE XU'�DIEIPARTMENTUSf ONLY Date ( Area -_ Employee ID#� Date 4 _ . F -I SPECIAL PERMIT - Approved by Pit/Sump Soil Character: -__ -- - - PE SC INFO Received B Check#/ Cash Amount Remitted Date Permit/Code Service Re uest # Invoice # Permit ID# r f . Al 42-01 5/5/17 /rte^ 0 oS-` ONSITE WASTEWATER TRTMNT SYSTEM PERMIT