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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 E XPIRES 21 YEAR FROM DATE ISSUED JOB ADDRESS ��C�V` -(f CITY/ZIP�2��1 q SJ 04 y CROSS STREET `u" APN Do / PARCEL SIZE I v / v OWNER NAMEpp l� PHONE [.tel �i OWNER ADDRESS T fC C I r S k 7-L(7/ CITY/STATE/ZIP CA CONTRACTOR C f1 V--5A1 P—V CONS bf Z- ZJV(g PHONE T � . LIeL0 G L� e"4{CONTRACTOR ADDRESS X2 Y � LICENSE I I IC-42 I II C-36 OTHER 2GC NUMBER EXPIRATION DATE l� Ad �9 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: I RESIDENCE I I COMMERCIAL C: 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 ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES I I 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 YM ft LI MOUNDED WIDTH ft LENGTH ft DEPTH_ 1I MPA1t� DISTANCE TO NEAREST WELL ft FI-)UNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH 9 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE P ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH IV JO, ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINA VIRO COON ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH T Aft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Tft 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 C7,VUM ENSATION LAWS. MINI 48 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE OWL DATE , DEPARTMENT WSE .ONLY ( ( Application Accepted By om/ Date f1 00 Area CC Employee ID# A),l nA Final Inspection By � u`20 Date FI SPECIAL PERMIT-Approved by Character of Soil to D {h ofA Ort: Pit/Sump Soil Character: CO E TS 4 .z Pot,J-O j: ra.+c -3S-7,r►+` &-,frx r kms /9 PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO B sh Remitted Service Request# Z22 0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17