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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-769_7 FOR INSPECTIONSI EXPIRES 1 YEARFROM DATE ISSUED JOB ADDRESS 7 ✓1/u-i,,e2,;oy CITY/ZIP LD f0(Z S2 ?J CROSS STREET PWII o APIN C%lPARCEL SIZE Q o OWNER NAME BZ CE PHONE OWNER ADDRESS ZZ �0 ✓ bEf" n1 ST-bo Ax Zo��_CITY/STATE/ZIIP/ L Oak{Z7�'� ,G4 SZ 3 CONTRACTOR�� CO. S i 11LACr-TOj PHONE Tr�J /y79�2ySS CONTRACTOR ADDRESS "0 ?Ox z7a y to CITY/STATE21P L LK �R��E ` -,�1157 Sj LICENSE 111/42 17 C-36 OTHER NUMBER J&fpe EXPIRATION DATE � � WATER TABLE DEPTH:.00 jVn 1—I � ft GEOGRAPHICAL INFORMATION: Coordinates X Y 7 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: y RESIDENCE I COMMERCIAL E-1OTHER NUMBER OF LIVING UNITS: .l NUMBER OF BEDROOMS: —3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CoAve. CAPACITY 120c) gal #OF COMPARTMENTS '2- 0 ❑ GREASE TRAP TYPE/MFG 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 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 Z^ WIDTH 6,C)" ft DEPTH 2-,S ' ft DISTANCE TO NEAREST WELL ft FOUNDATION Al ft PROPERTY LINE /D 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. MINIMUMOHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE �rc5 L[G.tit DATE /2- f l8l g 1 J '4 CD Cj O O Q L L �►„� All DEPARTMENT SE N Y Application Accepted By 4,001 Date 2 Area Employee ID# � _ i Final Inspection By Date Z Z ❑ SPEC AL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS lam( (V' S �� PE SC Receive Che Amount Date Permit/ Invoice# Permit ID# Code INFO —_By Cash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17