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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT f f SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVUN-NEFUNDABLE FERMI] CALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] JOB ADDRESS (4 /t-4 -ejy-i► t' rr- � _ / `CATTY/ZIP �LJ+q t P - 7 C/ CROSS STREET �i r'r , T�}��„[� APN _ Z �b_ O - (/� PARCEL SIZE --7 OWNER NAME T( LL(_`Z CSU \ t t4✓t4 ,` PHONE (T- � OWNER ADDRESSSi/ CITY/STATE/ZIP 1-4 l�e .�I l .3 n N ' J, CONTRACTOR L/b 1� 41- S �.�L�C I� N-1.- % �1 PHONE � � l `4[Cc' CONTRACTOR ADDRESS /o A�f -- 4e 5� -o CITY/STATE/ZIP LICENSE 1 1 C-42 Lh C-36 OTHER NUMBER 2 EXPIRATION DATE a Is WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/ADC inates X Y LAND USE APPLICATION # ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT -OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: �iESIDENCE ❑ COMMEL ❑ OTHER NUMBER OF LIVING UNITS: ( NUMBER OF BEDROOMS: V NUMBER OF EMPLOYEES: l9Y SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL toe) ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT tir'LEACH LINES I LEACHING CHAMBERS DISTANCE TO NEAREST WELL 19'50 f 9'50' ft FILTER BED WIDTH ft LENGTH I gal # OF COMPARTMENTS_ gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) I __ # OF LINES t-1 p LENGTH OF LINES D 0 _ ft 1 FOUNDATION -ft PROPERTY LINE ft ft DEPTH ft ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft DEPTH ft 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. SIGNED TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 1209) 953 - TITLE DATE DEPARTMENT S O LY 4&RApplication AccepteXB(4 Date Area Employee ID# Final Inspection By Date td L SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: 64!* Pit/Sump Soil Character: COMMENTS PE Code DISTANCE TO NEAREST WELL Amount Remitted ft FOUNDATION Invoice # 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 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft DEPTH ft 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. SIGNED TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 1209) 953 - TITLE DATE DEPARTMENT S O LY 4&RApplication AccepteXB(4 Date Area Employee ID# Final Inspection By Date td L SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: 64!* Pit/Sump Soil Character: COMMENTS PE Code SC INFO Received B Chec s Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 Y O b