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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Itc v"' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT �j CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS IZ27G T AL�Qj e-1 d e/ �V 2 CITY/ZIP�L aoi P-o'' -r_5-: ..Z� L CROSS STREET Fel-be, iZ4' APN D0 % 17© �O/7 PARCEL SIZE ` 74,0- p IV v tler•n J � ier�—•I V*Z —r7637 OWNER NAME �/ PHONE L u OWNER ADDRESS ^^��1��6� •' ��'e I CITY/STATE/ZIP A" ��i �`1 �7 S-2 J � CONTRACTOR Ifs"/421rJ� 5� /,fte-- PHONE ;?Of — CONTRACTOR ADDRESS 1,51 TG p ��f �2 p CITY/STATE/ZIP LICENSE I I C-42 I I C-36 OTHER NUMBER 3 `aVw EXPIRATION DATE 0 7— WATER WATER TABLE DEPTH: GEOGRAPHICAL INFORMATION: Coordin tes X Y PERC TEST # BUILDING PERMIT# AND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION PAIR/A 1 ON ENGINEER DE IGNED/ALTERNATIVE R 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 �' ' �t ��f�a/' CAPACITY vU gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELLS 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 QO( ft DISTANCE TO NEAREST WELL_&W cf ft FOUNDATION� ft PROPERTY LINE 's ft ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft U MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH ez_ ft LENGTH ft DEPTH �� ft DISTANCE TO NEAREST WELL /4' 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 AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDI CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIV ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPEN ON LAWS. MINIMU U ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953,7697 1 SIGNED TITLE DATE C T bM J D C U ry eA T Mill , H11111 cD PARTME Wlk SWE afN A Y Application Accepted By AL Date Area IM Employee ID# Final Inspection By Date: ❑ SPE IAL PERMIT-Approved by Character of Soil to Dept of 3 Pit/Sump Soil Character: COMMENTS _ ;✓' ' PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO By sh Fiernitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17