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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN(.NUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-QEFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Z B 3 CITY/ZIP ST U cV-- , c' 5'j 9-S 1 6 q CROSS STREET LV N \�( C L V C �� APN i ` �O U PARCEL SIZE 4 y3 y 0 v z OWNER NAME �/j // L'S— 6/ l PHONE MAI .OWNER ADDRESS /I h/XL ��/ �� --CITY/STATE/ZIP �!( YL�JIA i M V CONTRACTOR 11S 4G �C `' L �-�% `�` V!�X L PHONE Z C) ) �o Z ?j I CONTRACTOR ADDRESS x r C L A Z��5 �J `R � � ICO CITY/STATE/ZIP I'\ LICENSE LI C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH:/0( (/C) 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: ❑ SEPTIC TANK TYPE/MFG fkh'0fAAA-q 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 PUM11 �w - LEACH PKG TX PLANT ❑ SAN OIL SEPARATOR(ENCLOSED SYSTEM) _. r LINES I 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 COMPENSf1TION LAWS. qF MINIMUM al HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED � TITLE `r Z DATE 2 I J OCO r4 N �EPARTMENT L01.13E NLY Application Accepted B Date_ Area Employee ID#� Final Inspection By Date %dA �" ElSPECIAL PERMIT-Approved by Character of Soil to pthfo3t: Pit/Sump oil Chara ter: COMMENTS Q PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Re nelst�# LAO 42-01 l��W !/�{V�U ! L/ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17