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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P ✓' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I cyn '� 3� r,&�/ - l.� c"U�s 7� CROSS STREET I�/I 1 It to qt, �l�rw APN OWNER NAME d -e 1 /L° � TG, c I rnrb I CITY/ZIP / L -/30� U It GEOGRAPHICAL INFORMATION: Coordinates X Y _ b�j PARCEL SIZE # OF LINES BUILDING PERMIT # LAND USE APPLICATION #IrA U TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION PHONE FOUNDATION J OWNER ADDRESS �J/��y CITY/STATE/ZIP CONTRACTOR I I �I�/�y/T/ PHONE --?o CONTRACTOR ADDRESS /S O y /, CITY/STATE/ZIP LICENSEC 42 I 1 C-36 OTHER NUMBER ` �7� EXPIRATION DATE WATER TABLE DEPTH. U It GEOGRAPHICAL INFORMATION: Coordinates X Y L PERC TEST # # OF LINES Date BUILDING PERMIT # LAND USE APPLICATION #IrA U TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER D SIGNED /ALTERNAj1lYE FOUNDATION REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION INSTALLATION WILL SERVE: Ll RESIDENCE L COMMERCIAL L OTHER LENGTH NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ft ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Received B Cash # OF LINES Date 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 ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOJNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It 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 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. MINIMUM MHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 1209) 953-7697 SIGNED �� `^�� TITLE 4:�_ekoQY DATE q—a.?—'/, I EPARTMENT SE Y Application Accepted B Date Area Employee ID# Final Inspection By Date L SP IAL PERMIT M`►IT Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: RECEIVED COMMENTS APR -2 3 2018 PE Code SC INFO Received B Cash Amount emitted Date Permit/ Service Request # In E�1y IRON ENT rmit ID# l4`L1'H DEIAR NT 10.1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17