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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN 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 ISSUED � JOB ADDRESS ��J"��I�I J V/Qo CITYRIP 1� C1 p ROSS STREET /�(N 1 �'{ i" 1'A APN �� ? PARCEL SIZE OWNER NAME��0 ( PHONE OWNER ADDRESS —L / 1. 11SEWO flG A4M CITY/STATE/ZIP CONTRACTOR / r C r ems.✓ PHONE J�,, �J / CONTRACTOR ADDRESS "�J�% /�� `y �� CITY/STATE21P z,;2ej �► / Z �- LICENSE 1 1 C-42 I I C-36 OTHER NUMBER-7/57�3 EXPIRATION DATE Ss'/ X G �j� ( WATER TABLE DEPTH:; `' ft GEOGRAPHICAL INFORMATION: 1.1 PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/ADL Coordinates X Y LAND USE APPLICATION # )N ENGINEER DESIGNED at REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM -J DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE _) COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: J NUMBER OF BEDROOMS: Z- NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG rA CAPACITY �1i� gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL / (OU r ft FOUNDATION 30 ft PROPERTY LINE �0 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) TERNATIVE ❑ LEACH LINES 4 LEACHING CHAMBERS O, '2- `i # OF LINES LENGTH OF LINES^ ft DISTANCE TO NEAREST WELL�S� ft FOUNDATIONy ft PROPERTY LINE �Ei - ft ❑ FILTER BED WIDTH ft LENGTH Date Permit/ Service Request # ft DEPTH ft 0 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 COMPENSATION LAWS. SIGNED —lL lL1y1dr' TITLE / rte/ ice^ DATE Application Accepted By Final Inspection By 1/ Character of Soil to Depth of 3 Ft: COMMENTS TMENT USE ONLY Date_ > Area Employee ID# Date c/T%/ ,(!5- n SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE Code Sc INFO Received Y Check#/ cam Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 0 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17