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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 � S/5" 5 S s�CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB DDAES -' �� r��1J �� CITY/ZIP �? r n CROSS STREET APN )j q& 4 U J 3 PARCEL SIZE 6 . l./-5 y -II J O OWNER NAME (,7 `� A A �A n u d64""PHONE OWNER ADDRESS C 5 U CITY/STATE/ZIP r CONTRACTOR, �GS / L /G�l G/lt,� ' PHONE +7''X CONTRACTOR ADDRESS /�CJ �,y ��T/�.�ll)`� ,�z _ _ CITY/STATE/ZIP S-7' --— 4�7, q'k"2w'Z13J LICENSE I , C-42 I I C-36 OTHER NUMBE 995w- EXPIRATION DATE WATER TABLE DEPTH: y lO S 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 LJ COMMERCIAL //__�� LlOTHER NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: 40_0A NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY : (,�e5,L,5 gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS t � DISTANCE TO NEAREST: WELL ft FOUNDATION Z_ 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 �r� ft DISTANCE TO NEAREST WELL ��fi ��-' ft FOUNDATION I/S ft PROPERTY LINE J 1 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 It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH _ It 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 /j ft DEPTH 7� I _ ft DISTANCE TO NEAREST WELL,, S ',L ft FOUNDATION ft PROPERTY LINEA 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 COMPENS ION LAWS. MINI HOUR AQUANCE N TICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE: �� DATE��2- LL Z CN O I— Cj O DEPARTMENT USE ONLY f Application Accepted By Date IO-15 -If Area Employee ID# � AH�_ Final Inspection By Date 1<�API 1-1SPECIALPERMIT-Approved by Character of Soil to Dept�of Pit/Sump Soil Character: COMMENTS PE SC Received eck#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Remitted Service Request# ► lg �G 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17