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ONSITE VIfASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CAL 09 9$3-7697 FOR INSPECTIONS tXPIRES 1 YEAR FROM JJATE ISSUEI JOB ADDRESS O � C TY/ZIP CROSS STREET% APN C�/PARCEL SIZE'^ ��.y� OWNER NAME ^/ I. / 1 11 5, �/ �� Y _ PHONE( / 00,T4J — V__&,GZ OWNER ADDRESS % ��j 161 1c ` CITY/STATE/ZIP ^� u CONTRACTOR/� 1 ✓ �� A �S2'N e-^ PHONE CONTRACTOR ADDRESS / "O C�" y G e'e- L"� CITY/STATE/ZIP __,_._ �� G//7• ��^ LICENSE ❑' 'C-42 ❑CSC -36 OTHER NUMBER��53 _EXPIRATION DATE` 1 O liq WATER TABLE DEPTH: qO ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # _ TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNA IVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 19 NUMBER OF EMPLOYEES: Ef SEPTIC TANK TYPE/MFG �� Cr CAPACITY Z� gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG •/ CAPACITY gal # OF COMPARTMENTS Amount Remitted DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE An ft ❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) Permit ID# '"(LEACHING 2 LENGTH OF LINES/ 49 j It LEACH LINES CHAMBERS 7 # OF LINES ,73, 00 DISTANCE TO NEAREST WELL FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH _PPAYAsp. _ ft lr�fVft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH vell ft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE J'qft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH /^. ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY/l/NV/V/N, `Cn,, ft LT O"E��nq�E�TA"C Ll 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. MINIMU HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 A61 �1001 SIGNED �- TITLE _ DATE / Z - lJ � EPARTME TU E NLY Application AccepteAof Date Area Employee ID#� Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to it/Sum oil Character: COMMENTS{/OLIJ/ PE Code SC INFO Received hec ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 1 ,73, 00 2 s O _72 6 1y 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17