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ONSITE WASTEWATER -TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN-T-- -- ,186&-E,-HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT'`' f CALL 209 953-7697FORINSPECTIONS hXPIRES 1 YEAR FROM UATE ISSUE JOB ADDRESS 171 -5vY !"/ ` CICITY/ZIP% C CROSS STREET 4eA,,57& fG 1 P&grMyLE /� ed APN ✓ o i l- PARCEL SIZE 0,%v OWNER NAME W l LG/gh I i C. AC"4ff _ _ PHONE nom, / o D- �lr?im OWNER ADDRESS SAn` -CITY/STATE/ZIP CONTRACTOR CONTRACTOR ADDRESS LICENSE ❑ C-42 ❑ C-36 OTHER PHONE ATE/ZIP NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # I YPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM K DESTRUCTION TLf A 1't i;JSTALLATION WILL SERVE: ❑ RESIDENCE 'I COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MF ❑ 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 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. ADVANCE NOTICE REQUIRED FOR INSPECTIONS - SIGNED W' "t .1/l/ TITLE 0 wAhn DATE 10 I Application Accepted B LoI Final Inspection By Character of Soil to th Tf ift, COMMENTS Goo Lc R V, - Goy Ga / DEPARTMENT USE ONLY Iq i 6' Date - / Area C Employee 1D# 00 Date 1 ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: cN c ; cn tcr- n K C rt r.t c al f� 'IYA M ft ft ft ft ft ft ft ft ft ft ft PE Code SC SC INFO Received By Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 4t') o s � 3� Z. )-2, 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T m Y 0 0