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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAP; J�AQUIN ICOUNTY 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 Li�4�CS *:% IQ,/ Y__ _ / Ft�vw3w CITY21P�WLI I ��/ 7�!/. CROSS STREET 1/7 V i APN — 7 PARCEL SIZE -� OWNER NAME![t/I�1 {��C/I L.sl� PHON'��LSLC7 �J OWNER ADDRESS �� CITY/STATE/ZIP CONTRACTOR /(� PHONE CONTRACTOR ADDRESS LICENSE I I C-42 I1 C-36 OTHER CITY/STATE/ZIP NUMBER _ _ --_ _ _ ._ EXPIRATION DATE WATER TABLE DEPTH: i`! _LL 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: RESIDENCE D COMMERCIAL J OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS 'L/ gal l/gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) i 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953- 69 SIGNE TITLE D(/( /ta1%� DATE 1b(_kPARTMENTJtS&O1VLY Application Accepted By Date [� Area WEmployee ID# A&"f Final Inspection By Date ZO / b n SPECIAL PERMIT - Approved by Character of Soil t h Ft: CZPit/Su'p Soil Character - COMMENTS 1614�r (-6n� � r-�Q_k lo,� !? �n�--f � _,�- I r� Lvvt-(✓��-- rrn �-/Z ill � PE Code LEACH LINES J�EACHING CHAMBERS Amount Date Remitted # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL Oby ft FOUNDATION ( It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It 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 DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION _ It 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953- 69 SIGNE TITLE D(/( /ta1%� DATE 1b(_kPARTMENTJtS&O1VLY Application Accepted By Date [� Area WEmployee ID# A&"f Final Inspection By Date ZO / b n SPECIAL PERMIT - Approved by Character of Soil t h Ft: CZPit/Su'p Soil Character - COMMENTS 1614�r (-6n� � r-�Q_k lo,� !? �n�--f � _,�- I r� Lvvt-(✓��-- rrn �-/Z ill � PE Code SC INFO Received eck#/ Cash Amount Date Remitted Permit/ Service Request # Invoice # Permit ID# I *;�� tW%79062_ I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 LA