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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NOON -REFUNDABLE PERMIT JOB ADDRESS 4A t L CROSS STRE OWNER NAM CALL 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED n �( CITY/ZIP zxiel APN //�� V U Q 0 101 PARCEL SIZE O• I 1J Jr M�ChePPHONE 0_..4„ OWNER ADDRESS %l/V /V/N"✓/ �J�fL�CITY/STATE/ZIP- CONTRACTORfY�J ( R / V PHONE CONTRACTOR ADDRESS A96) /te� L 1 U CITY/STATE/ZIP LICENSE E C-42 DOC -36 NUMBER EXPIRATION DA WATER TABLE DEPTH: G ft GEOGRAPHICAL INFORMATION: L ` PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/ADC Coordinates X Y LAND USE APPLICATION # IN ENGINEER DESIGNED RGDi ArceecuT r1uT-CIF-SFRvICF SFPTIr: SVSTFM F1 DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: TERNATIVE ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ 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 Ss ft DISTANCE TO NEAREST WELL UD ft FOUNDATION N .G ft PROPERTY LINE G 'IF It ❑ 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 It PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER I WID��T,H,,,��yy `�� / Ir- DEPTH o' S / ft DISTANCE TO NEAREST WELL_(Vy� it FOUNDATION ti2U ft PROPERTYLINE_,Q i" 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 LA1AC MINIM 24 RNCE NOTICE REQUIRED FOR INSPECTIONS - PE CALL 209 953-79Q'7 SIGNED x _ TITLE C� _ DATE 1�� Application Accepted By _ Final Inspection By Character of Soil to Depth COMMENTS Ad DEPARTMENT USE ONLY r� Date 1O - S j Area q -I Employee ID# - Date_ L ❑ SPECIAL PERMIT -Approved by _ Pit/Sump Soil Character: PE Code SC INFO Received By Check ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# _1140 t,6 tu 33 �D s I S W78� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17