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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ) tev// SAN JOAQUIN 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 A G► ei ✓ CITY/ZIP ASM 100 CROSS STREET �+ Q /� P* t/% %! 4 may. APN e `' PARCEL SIZE D. OWNER NAME �TP44 _ _ PHONE OWNER ADDRESS.%� CITY/STATE/ZIP CONTRACTOR Lt ,�e 1,/�� PHONE Q f l CONTRACTOR ADDRESS �O �/' / ip / CITY/STATE/ZIP e'h"fi/ 7�' e LICENSE r�'� C_42 CI' C-36 OTHER NUMBER 977-SOEXPIRATION DATE_ D � 1 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y El PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATI N REPAIR/ADDITION ENGINEER DESIG ED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTIO FINSTALLATION WILL SERVE: RESID CE H COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: IH' SEPTICTANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY %,Z S l% gal # OF COMPARTMENTS Z 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 ❑ 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 PAL Y4nle\ems. ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY ft ❑ SUMPS WIDTH _ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYSI�I�� ft ❑ DISPOSAL PONDS WIDTH _. ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER �RfE`QUIN COIINTV ft ❑ SEEPAGE PITS NUMBER __ ry VIRZS N � WIDTH ft DEPTH HEALTHBEfl1 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9553-7697 SIGNED- TITLE DATE 1 �� 00 Application Accepted By DEPARTMENT U 'E 0111"Y Date Area Employee ID# ftYFJCM�Pit/Sump 4_1 ' Final Inspection By Date I I SPECIAL PERMIT - Approved by Character of Soil to D h Soil Character: COMMENTS PE Code SC INFO Received B 1<heQW Amount d Permit/ Date Service Request # - Invoice # Permit ID# D7 �emitt /U�`� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 V: