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ONSITE WASTEWATER TRS A-fMENT SYSTEM PERMIT 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 ISSUE JOB ADDRESS / r CITY/Zip CROSS STREET ' ' APN l Z'cJ `� �T' PARCEL SIZE OWNER NAME PHONE OWNER ADDRESS ,J CITY/STATE/ZIP CONTRACTOR - lli f��(L' ) / l� �f �.K✓% - PHONE -J CONTRACTOR ADDRESS fi�^'� _CITY/STATE/ZIP /� 'I LICENSE F1 C-42 ❑IJC-36 OTHER / NUMBER- ? - ' - EXPIRATION DATE WATER TABLE DEPTH: ft ❑ PERC TEST # I I BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPLACEMENT INSTALLATION WILL SERVE:-f7�'*kSIDENCE NUMBER OF LIVING UNITS: GEOGRAPHICAL INFORMATION: Coordinates X LAND USE APPLICATION # I i OUT -OF -SERVICE SEPTIC SYSTEM L f COMMERCIAL NUMBER OF BEDROOMS: �l 9 ENGINEER DESIGNED /ALTERNATIVE DESTRUCTION �I OTHER A!, NUMBER OF EMPLOY E(% '• -�� ❑ ❑ ❑ SEPTIC TANK TYPE/MFG GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ft _ LIFT STATION SIZE TYPE OF PUMP CAPACITY gal # OF COMPARJW CAPACITY gal # OF COMPARTMENTSA,NS_ TY L Ulfv rr,, , ft FOUNDATION _ ft PROPERT I ❑ PKG TX PLANT ❑ SAND OIL SEPARAiMA 9W T%) RTINENT C Cash LEACH LINES LEACHING CHAMBERS # of LINES- LENGTH OF LINES T(/ ft /l DISTANCE TO NEAREST WELL %�� It I / FOUNDATION 7" ft PROPERTY LINE �f " It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It 0 DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH It LENGTH it DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It SUMPS WIDTH _ It LENGTH �J ft DEPTH - z � It DISTANCE TO NEAREST WELL ft l FOUNDATION 1® ft PROPERTY LINE �r f' T ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE It 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. 11A►AI►AArLAN oar unt 10 A n11A AL&<= A/nTu-= O=niiiacn =nQ 1)UQVJTrT/niUC - DI ;7A 'Z17 CAl I /9/1Q1 01;Q-7907 SIGNED ■■ilii■I■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■lei■'�J!■■r■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ I ' iowl,• f I=-JWYJM ism • PE Code SC INFO Received 13Y C Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# Z I '10-t 0 42-01 9' ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 U