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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE /PERMIT CALL 209 953-7697Fon INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS CITY/ZIP %� O IA - CROSS STREET �e 1 �•�yzoaa/ A P N /) ,n7��V "" D / PARCEL SIZE Ras OWNER NAME i I V PHONE OWNER ADDRESS 'A _CITY/STATE/ZIP 1� CONTRACTOR ` ' Y q 11M S'PhI G. PHONE CONTRACTOR ADDRESS C? 31(t 0/50m rim CITY/STATE/ZIP LICENSE Ll )(C-42 ❑ C-36 OTHER NUMBER �S9O45- EXPIRATION DATE ` �� /� J 1 A N% 1 I _ WATER TABLE DEPTH: U M U ft GEOGRAPHICAL INFORMATION ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION X REPAIR/ADI Coordinates X Y LAND USE APPLICATION # IN ENGINEER DESH REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM _ DESTRUCTION _ INSTALLATION WILL SERVE: RESIDENCE 11 COMMERCIAL El OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYE ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG Lr'l g;,lq CAPACITY TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMP&W6TS gal # OF COMW41L, � UI A ft PROPERTY LINE THOEPAP'.. L ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTE ) XLEACH LINES LEACHING CHAMBERS # OF LINES Z LENGTH OF LINES �O ft DISTANCE TO NEAREST WELL %OO ft FOUNDATION ft PROPERTY LINE GQO 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 3 WIDTH 3 ft DEPTH _C95 , ft DISTANCE TO NEAREST WELL ISO ♦ ft FOUNDATION �� ft PROPERTY LINE (p0 ♦ 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. will YnnUirn nvvn nuVMIVL,.c IYv/l{rc n':wU/nCL/ "'n IIYJr/CLIIUIVJ -rLCHJC 1,ALLLU.7y.7J-/Uy/ SIGNEDTITLE c.Oc4�ltL DATE 6 Application Accepted By Final Inspection By Character of Soil to Depth of COMMENTS Date Date S I Area At-10Employee ID# ❑ SPECIAL PERMIT - Approved by it/Sump Soil Character: PE SC INFO Received B h Amount Cash a 'tted Date Permit/ode ervice Re uest # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r� Y O O z M