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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED yJO .� B ADDRESS CROSS STREET rJ It 1100 APN��T �' I O / PARCEL SIZE > d OWNER NAME �/ �/��l ✓l CK PHONE 145 OWNER ADDRESS r� CITY/STATE/ZIP CONTRACTOR '1'�L1J rc.K�i 3�✓ Gi PHONE 115L CONTRACTOR ADDRESS pi7 A -fes ��J L' CITY/STATE/ZIP C�1�a'/I iii- 1 •5�.1 LICENSE L iC-42 I_I I 'C-36 OTHER NUMBER V 5 EXPIRATION DATE - Q WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y I-1 PERC TEST # BUILDING PERMIT# / LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION 1 R PAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE I REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM II DESTRUCTION INSTALLATION WILL SERVE: 1 RESIDENCE I COMMERCIAL 91_ OTHER f UMBER OF LIVING UNITS: NUMBER OF BEDROOMS: p NUMBER OF EMPLOYEES: ` SEPTIC TANK TYPE/MFG f'L CAPACITY 4P 50gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS e � � DISTANCE TO NEAREST: WELL it FOUNDATION s ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES CI LEACHING CHAMBERS #OF LINES LENGTH OF LINES ti, ft ( / DISTANCE TO NEAREST WELL 1 .0Aj ft FOUNDATION / ft PROPERTY LINE •'S 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 Pift DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �I11 ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH M Ai n ft DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LIN 70mft JOAQU ft L3 SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINL 11y/ - _N u rVTW Elv r 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. 1 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. MINIMUM 48 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)1i953-76997 y SIGNED TITLE DATE a J LL I D PARTMENPUSE40NLY Application Accepted By Date Area 3,b4mloEmployee ID# Final Inspection By tib Date '4)17 ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received he Amount Date Permit/ Invoice# Permit ID# Code INFO B ash Remit d Service Request# /S 1-2i-11) S4_1 0) \?AD 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17