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ONSITE WASTEW / ENT SYSTEM PERMIT s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM!7 7 tv `� / h 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT ALL -NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS// CITY/ZIP CROSS STREET M � 141,C APN , JY 0 � S PARCEL SIZE 1./ OWNER NAME "' 0 re PG ir K Y rG✓ t � � � S L 1 / PHONE ZDq Ito -7- 0,69Z I OWNER ADDRESS U �s— y �S GI (j/ Q A //.Q CITY/STATE/ZIP V r Pt /1 bra Q CONTRACTOR /t/JLIf�(_A}%tom®'� �L `� �" PHONE CONTRACTOR�ADDRESS �/ % '1 / I %� V � � �/ CITY/STATE21P LICENSE Er -C-42 LI' C-36 OTHER NUMBER J3 EXPIRATION DATE WATER TABLE DEPTH: 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 COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:NUMBER OF EMPLOYEES: 21 SEPTIC TANK TYPE/MFG f �i �u L/� 2 CAPACITY al # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS f DISTANCE TO NEAREST: WELL AS -0 ft FOUNDATION ! 0 _ 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 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 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 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 COMPEN4,&ION LAWS. MINIMUM 24HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE <!;�k& r DATE CF;/ 6,-/X Application Accepted By� Final Inspection By Character of Soil to Depth of COMMENTS ('Mft'lt- - Date Date 612 ISE NLY 57 il/?{ q Area Employee ID# fq;P�Q❑ SPECIAL PERMIT -Approved by Pit/Sump Soil Character: PE Code SC INFO Received eck#/ Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 4215 2 I UWJ 1 ttjt_l3r 1� I( S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17