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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 L (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM UATE ISSUEI JOB ADDRESS / j f�-0-;Z I ff /f% - AK 1 y% CITY/ZIP 4469�Z4C C—Or '_f_ / =22J ,/t CROSS STREET l A1/ APNI -I ly `� _ PARCEL SIZE O/� OWNER NAME /��/ �// +LV l�iC�� j PHONE Z09 v�,oe' e QWNER ADDRESS/ ��L� GJ/1[t�T�Ly�� —L/IC6�_ CITY/STATE/ZIP 2� Q� / PHONE i �/ CONTRACTOR {�O� CONTRACTOR ADDRESS D `VD�d ✓o / CITY/STATE/ZIP 67�� /4*9 - 9-9-�� LICENSE ❑' C-42 ❑ C-36 OTHER NUMBER W7EXPIRATION DATE ` u WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST If BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION i REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION 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 CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft . ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH It LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH It 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. Ilcl1101] Application Accepted By Final Inspection By t�Cl Character of Soil ;u Depth of 3 Ft: COMMENTS TITLE DATE Z " / ` ft ft ft ft ft ft ft ft ft ft ft ft �/I DEPARTMENT U E ONLY f�� Area d1JAA Employee ID IA16;� Date ❑ SPECIAL PERMIT - Approved by Pit/sump Soil Character: PE Code SC INFO Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# J %0 Z 2(plb - UI 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17