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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 _ NON-REFUNDABLE PERMIT CALjL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED )t1111 ;zo JOB ADDRESS d ` CITY/ZIP • CROSS STREET �/Z©A) Z_4A) APN �tI'l � PARCEL SIZE OWNER NAME (ff/ r1l 4 OWNER ADDRESS 101 (/Y i/ / (.T.�/1 �I%s �� TY/STATE/ZIP ��ift1 %C/¢ ,Q�-'J, i 3_3 CONTRACTOR �- ` �V S PHONE � `J� 6 CONTRACTOR ADDRESS / CITY/STATE/ZIP / 4-A� , -/ LICENSE 1_1' C-42 Eli IC -36 OTHER yf NUMBER EXPIRATION DATE / 12 eI g.01 'If F.Ar WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE ft PROPERTY LINE 1-1 REPLACEME T OUT -OF -SERVICE SEPTIC SYSTEM x DESTRUCTION�pl INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ,,1:5;'SEPTICTANK TYPE/MFG ._ CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal # OF COMPARTMENTS ft PROPERTY LINE DISTANCE TO NEAREST: WELL It FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP_ _ __.. O PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES I` LEACHING CHAMBERS # OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION It 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 ft PROPERTY LINE ❑ SUMPS WIDTH _ It LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH I It DEPTH DISTANCE TO NEAREST WELL It FOUNDATION It 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. MINIMU H DVANCE i OTICE REQUIRED FOR /NSP CTID - PL E E CALL 209 953-7 97 AL SIGNED n TITLE DATE t DEPARTMENT All Y Application Accepted B Date Area Employee ID# Final Inspection By Date I� SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: P t/ ump Soil Character: COMMENTS It It It ft ft ft It It ft It It It PE SC INFO Received B Check#/ Amount Cash emitted Date Permit/Code Service Request # Invoice # Permit Ili 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T