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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ILP'-' 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 4 n ' ` Q I I I'S (`K -C t to A/3 CITY/ZIP y0 CROSS STREET / D T .� APN -� 40 y PAAsRCEEL SIZE OWNER NAME 4eny[Qa dty Q tz!y PHONE OWNER ADDRESS `, S� �VV J �C Jrc LJGI '[�^1n L 2z5 -W CITY/STATE/ZIPL U Q CONTRACTOR IG.�r . PHONE CONTRACTOR ADDRESS b lsl CITY/STATE/ZIP LICENSE i I C-42 I I C-36 OTHER L NUMBER 95 EXPIRATION DATE! I 0 O r DEPTH ft VI WATER TABLE DEPTH: It 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: ESIDENCE ❑ COMMERCIAL Ll OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 4 NUMBER OF EMPLOYEES: 11l,"SEPTIC TANK TYPE/MFG ?P !LL CAPACITY b gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL O t ft FOUNDATION ( ft PROPERTY LINE % ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft Permit/ Service Request # DISTANCE TO NEAREST WELL 10al ft FOUNDATION -7S+ ft PROPERTY LINE ! -1 ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft Ne Y DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ 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 �� WIDTH ft DEPTHI ft DISTANCE TO NEAREST WELL (S_ _ ft FOUNDATION Iw ft PROPERTY LINE LC�t 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 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED 6 TITLE (,OAd-fcCt-ar DATE I i EPARTMENT USE ONLY -t $ G� f• eq Application Accepted By Date Area -� Emgctz Final Inspection By Date_ / ❑ SPECIAL PERMIT - Appaby Character of Soil to Dep o t: PiUS mp Soil C aracter: COMMENTS e /)'l a-. B✓ rl 'ercl I- r ` �oP oNM �M Scf�r 0. Q ; PE Code SC Received INFO eck#/ Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# Ne Y 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17