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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / 7� L lw� I CITY/ZIP l oL� TGN SZ� v ROSS STREET /SLG KI -� ��/✓O �� APIN rQ � PARCEL SIZE 1 v CL oN �� Z�zB S/o- 9_3--991 OWNER NAME PHONE v OWNER ADDRESS �3 ITY/STATE21P llL T�/N �SzOZ CONTRACTOR !/�/, yc-• PHONE � � `I Z/ CONTRACTOR ADDRESS �f> C��!r 3i y�G CITY/STATE/ZIP LICENSE I I iC-42 I iC-36 OTHER GZ/j�/ NUMBER //2�z� EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 1 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: 7 RESIDENCE 1� COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH 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 It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE JOA 11. ft 11 LIMOUNDED WIDTH ft LENGTH ft DEPTH �,L� I�' ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE' ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH l-� ft 7 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY SINE I 21,12 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH SAN JOAQ1 114,C — ft wulv DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTrYEA tea_ ENS Ty ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH a�TMENr ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT 1 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. MINIMUh 4 R OTICE REQUIRED FOR INSPECTIONS-PL ASE CALL 209 953-76,97 SIGNED `~ TITLE —DATE Z PARTMENTAISIF ONLY Application Accepted B Date Area Aq Employee ID# Final Inspection By (�lldw�"� Date a z / I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 51PkL rtz�Y,K- 1462FV ad /l iAr—q G9s�R� PE Sc Received Check#/ Amount Permit/Code INFO B ash Remitted Date Service Request# Invoice# Permit ID# 42-01 O 7C��9G� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17