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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P✓ l SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT . CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 NEAR FROM DATE ISSUED JOB ADDRESS CROSS STRE OWNER _ APN CITY21P PARCEL SIZE • 347 PHONE S46 r 4'� I 1 6 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: [I PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION Ll REPAIR/ADE Coordinates X Y LAND USE APPLICATION # IN I1 ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM 7 DESTRUCTION 1 M (VU --j INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ❑ LEACH LINES ❑ LEACHING CHAMBERS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft _ ❑ PKG TX PLANT O SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE -M OWNER ADDRESS / / . J Ave CITY/STATE/ZIPC C' � �� (�/�,/� CONTRACTOR �f-a V/0 1(/I CONTRACTOR ADDRESS r llw� 6 l/ll ��' PHONE Uf] CITY/STATE/ZIP J+u") �V U 7I pcu s �' 1V`� M[ N 4 W l�_7CJIV LICENSE C-42 ❑ C-36 OTHER A NUMBER"++ 5 0 EXPIRATION DATE Lt 111 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: [I PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION Ll REPAIR/ADE Coordinates X Y LAND USE APPLICATION # IN I1 ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM 7 DESTRUCTION 1 M (VU --j INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ❑ LEACH LINES ❑ LEACHING CHAMBERS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft _ ❑ PKG TX PLANT O SAND OIL SEPARATOR (ENCLOSED SYSTEM) # 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 ft 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. SIGNI ft ft ft ft ft ft ft ft ft ft ft ft ■■■■ ■E■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■�i�l■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■111■■Z• ■■■. ■■■■■...........� ��.................■.�..� ■■■■■■■■■■■■■■■■■■■■■i ■■■■■■■■■■■■■■■■YMMINOWL" ■■■■■■■■■■■■■■■■■■■■■ 0000■■■w■■■■■■■■�z■��■ ■■0■0■■■■■■■■■■■■■■■0000■■■■■■■■■■■■■■■■■■■■ ■■00■■■■■■■■000■■■■■■■■■■■■0�■■■000■■■■■■■■0 ■■■■■■'■■N■■■■■■■■■■■■I■■■■■■■■■■■■■■■■■■■■■■■■■■ �R■■■ili ■■■1■■■■■■■■■■■■■■■■■■■■■■■■■■■■[:]"I ■■■■■■■■■■■■■■I■■■I■■■■mmmmm■■mmmm■■■■■■■■■■■ ■■■■■■■r■■■r■■■■E--mm■■■■m■■m■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ..N ._ .. .. • PE Code SC INFO Received By_ hec as Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17