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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT F ✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 Y NQN-REFUNDABLE PE IT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED IOB ADDRESS I 1-70L S uyo ZL7 CITYIZIP 5-co'-To Cls )S ROSS STREET N ��L=E`!G/.hJI��/{Z/ �� APN '�^� y '� 1 PARCEL SIZE p OWNER NAME jV `'/ "�/✓l% l/QU 1 t J V 10 LI PHONE OWNER ADDRESS ! CITY/STATE/ZIP CONTRACTOR`J� (.OIQ ST U C�/J 14 PHONE\-1(Le� Li) 1/-2-YS c� CONTRACTOR ADDF _SS �`'i � ��7 /� L/ CITY/STATE2IP E� 6r1(7OC' � �J , LICENSE IJ CC--4422 IJ C-36 OTHER NUMBER 7 Zz 1 �)(C EXPIRATION DATE C*AO �D WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y -1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/& TI 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: SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES V LEACHING CHAMBERS �4) - #OF LINES LENGTH OF LINES Sft DISTANCE TO NEAREST WELL I o o f ft FOUNDATION k 01-f e,-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 It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ti/SEEPAGE PITS NUMBER I WIDTH 341" ft DEPTH S 0 ft f DISTANCE TO NEAREST WELL �l , ` ft FOUNDATION I t) 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 COMPENIf�ION LAWS. MINIM HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE I Ci-E�F /✓T DATE Ug f7 I r All Pik c JEPARTMENTAISFJONLY Application Accepted ByDate Area Employee ID#� Final Inspection By Date 3 / t ❑ SPECIAL PERMIT-Approved by Character of Soil to DeP9 of t: Pit/Sump Soil Character: COMMENTS /1ZW, 694y.�'i z 1r9 r . �. 3► ,� 9► n� Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO Cash Remittp.d Service Request# lime $ SzwlCI o 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17