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SSI 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 I 0061 CITY/ZIP 0 2 Z— v CROSS STREET D, APN c �r�l� �� PARCEL SIZE y v �� v OWNER NAME r l AAPHONE I ,/�/� !� J. OWNER ADDRESS { �Y/!�l"l �CS - __CITY/STATE21P W01 A:� 1,572-q7, CONTRACTOR c 1 4D ( 1� r�,s PHONE CONTRACTOR ADDRESS /f� /( WL lil/ 9� CITY/STATE/ZIP LORS C, QI'7rZ�q`IZII LICENSE I I C-42 ❑ CI-36 OTHER ( '� NUMBER I EXPIRATION DATE �Zz WATER TABLE DEPTH: (�` ft GEOGRAPHICAL INFORMATIO : Coordinates X Y PERC TEST # BUILDING PERMIT# _ LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION R PAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: -,-"rRESIDENCE I COMMERCIAL THER NUMBER OF LIVING UNITS: )Q NUMBER OF BEDROOMS: x NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG T (/ CAPACITY fZ 00 gal #OF COMPARTMENTS Z� ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS I DISTANCE TO NEAREST: WELL �� ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) - - -- - _. �l LEACH LINES LEACHING CHAMBERS ZS #OF LINES LENGTH OF LINES I � ft CCS DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It 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 It 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 COMPENSAIION LAWS. MINIMUM,.Ph4'FI0UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE DATE P11 I r I LLA -� i i D ARTMENT USE O LY Application Accepted Byink Date/Olt-7I'_ Area 14 l Employee ID#W L Final Inspection By Date Lam/L F1 SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PAYMENT RECEIVED PE SC Received (LeckW Amount Permit/Code INFO B Cash RemittedDate Service Request# Invoice# OCTmf 7#201 2 SAN j0AQ IN GOUN7-Yw ENVIRONMENTAL DEPARTMENT 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17