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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT S AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVUN-MEFUNDABLE PERMIT CALL (2151.9)/9_53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS q lei i �fi _� 'J& CITY/ZIP CROSS STREETT Q ��/A�I: APIN 0� `AL - L/V PR SIZE 7h' OWNER NAME Lj � wLi / Q r y te-4 I PHONE Q,_0 s:s 6 __7 M OWNER ADDRESS �� 367�_CITY/STATE/ZIP L'- iiJ--^cC� CONTRACTOR, `�.S �l42C07 04'- Q1_ PHONE 41sc` CONTRACTOR ADDRESS Po 6 M 10 a CITY/STATE/ZIP 1'�r/tA4gCA • w LICENSE 11DC-42 I I C-36 OTHER NUMBER EXPIRATION DATE I WATER TABLE DEPTH: U U u ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: J RESIDENCE ❑ COMMERCIAL 1.0 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG D f"'L- CAPACITY 1� gal # OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION d�' ft PROPERTY LINE 3�1 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) R LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES , ft Date DISTANCE TO NEAREST WELL 1 ft FOUNDATION 101 ft PROPERTY LINE /.,n ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft 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 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER I WIDTH - 0 I, ' ft DEPTH cis ft DISTANCE TO NEAREST WELL ft FOUNDATIONI in, ft PROPERTY LINE S(1f 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-76g97 �/ SIGNED TITLE C G;4,j r DATE 1 % `)S Application Accepted By Final Inspection By__� Character of Soil to•D4K Cr1",M TENTS A/ V Area Employee ID# L) SPECIAL PERMIT - Approved by it I'hnrarfar- PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO By Cash Remitted Service Request # 1 O(b� 53 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17