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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 Foq INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSC t' ,2Y SS CITY/ZIP L LA CROSS STREET APN U (J/ LI PARCEL SIZE p 0 }� / ^mh ZG OWNER NAME ,9�C'da/0 �c°L I// l PHONE 1 OWNER ADDRESS /��P W C&�tlC YC CITY/STATE21P ,�' D C /y 1, CONTRACTOR PHONE_p o � '7 CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER _EXPIRATION DATE WATER TABLE DEPTH: - ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# d t LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAI ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 11I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: fj SEPTIC TANK TYPE/MFG 1{0 PV P )- L CAPACITY I O L) gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS i DISTANCE TO NEAREST: WELL /G U-, It FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) I.$ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES 1i'C) ft DISTANCE TO NEAREST WELL 100 ft FOUNDATION T ft PROPERTY LINE + ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE �P ❑ MOUNDED WIDTH ft LENGTH It DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LYE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ) 01R ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY�' Rn U/N�h�_ ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH �F �NT N'7 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE MFA,, ft ® SEEPAGE PITS NUMBER WIDTH 4�- jW DEPTH ft DISTANCE TO NEAREST WELL _ _ ft FOUNDATION .5V k ft PROPERTY LINE _ It I HEREBY CERTIFY THAT 1 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED �t'C✓4 �r.�^i\ ZD rC Z TITLE� [t1^O;r A IP DATE I Lj ti Application Accepted By 77, DEPARTMENT USE ONLY Area I Employee ID# Ai)m c 6J Final Inspection By W Date _ Ll SPECIAL PER T-Approved by Character of Soil to Depth of Pit/Sump Soil Character: COMMENTS PE SC Received Amount Date Permit/Date # Permit ID# Code INFO BV as Remitted Service Request# 11 ) 11 12gI 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17