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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 JOB ADDRESS CRO%S STREET OWNER NAME (:ALL (ZUY) JbJ-/6`J/ FOR INSPECTIONS LXPIRES I YEAR FROM UATE ISSUEI _ CITY/ZIP / -#% Coit'. APN/i� - � O - _ PARCEL SIZE PH OAER ADDRESS / ®/ f �C�tl � �� ( �C�/_ � CITY/STATE21P //o1J �%fC✓ <74f, CONTRACTOR _I) rJ'I �/�iD` Pe 0,,e %��' _ __ . PHONE 1-.&� l�J O -,61 CONTRACTOR ADDRESS �,�©/� 2 �'7 CITY/STATE/ZIP Z-/ 0/ 4:! • LICENSE 1_1 C-42 ❑ C-36 OTHER J5Ga NUMBER I 3 / EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y El PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION i I REPAIR/ADDITION I i ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL J 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 CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS It PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It 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 it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 LAWS. MINIMLY12 E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE .9CT�< DATE Application Accepted ByeAl Final Inspection ByA/C;Sx* Chdractur o, Soil to Depth of 3 Ft: COMMENTS T DEPARTMENT U EONLY Date�i Area Employee ID# Date Jf ❑ SPE IAL PERMIT -Approved by Pit/Sump Soil Character: PE Code SC INFO Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# G S (; '%0 2(IX3 R 42-01 5/5/17 I ONSITE WASTEWATER TRTMNT SYSTEM PERMIT