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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFI DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLEPERMIT SC INFO GALL ZU ) !AXf-1b91 FOR INSPECTIONS tXPIHE5 I YEAH FHUM UA I t IS5Ut JOB ADDRESS & t� Date CITY/ZIP P'.%i Invoice # D CROSS STREET 4� n� APN T PARCELSIZE MLe A cOtcze-n EA I 0 d OWNER NAME LS PHONE( - A- U&S tilu (C.� OWNER ADDRESS 1 42- CITY/STATE/ZIP CONTRACTOR 1' I ► i9-4'5 ��c3'C/ PHONE ;I ��^ SC�� �. CONTRACTOR ADDRESS R"[�) Q �/! �7 CITY/STATE/ZIP f<r e'14-�Lrw C►� LICENSE ❑ C-42 [IC -36 OTHER NUMBERI�-3i' EXPIRATION DATE 0 WATER TABLE DEPTH: '-V ft GEOGRAPHICAL INFORMATION: Coordinates X Y L PERC TEST # BUILDING PERMIT # _ LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION AIR/AD I ION i ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION x. INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER NUMBER OF LIVING UNITS: Q NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ® SEPTIC TANK TYPE/MFG "w -AA 'o�M- -u�G& CAPACITY ' Qr") gal # OF COMPARTMENTS !� ❑ GREASE TRAP TYPE/MFG �t. Conc,t-e-Ee. CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION _ It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP _ __ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES A LEACHING CHAMBERS ' # OF LINES_ LENGTH OF LINES �h ft DISTANCE TO NEAREST WELL�1�: U' _ ft FOUNDATION ' ft PROPERTY LINE U ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH _ ft LENGTH ft DEPTHI ijV1 Tft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE C� 11ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI Eft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH u JOAQUIN P _ ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROI�PERTYLIN�ALNMENTe��TMft SEEPAGE PITS NUMBER L WIDTH q;k d ft DEPTH .e1 C- TMENz ft DISTANCE TO NEAREST WELL ft FOUNDATION Ibf 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 HqVF ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE (�Sn��(S417' DATE Al DEPARTMENT USE ONLY � r,) Application Accepted B Date_. -.2& Area--'=�-t— Employee ID# v G r Final Inspection By Date _.[�t�__ ly [.J SPECIAL PERMIT - pprove by Character of Soil to Depth of 3 Ft:_ Q Pit/Sump Soil Character: �� *w-" COMMENTS PE Code SC INFO Received B hec Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 4� Z 122a1 C07 S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17