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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 �t�P.yEERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAT ISSUED JOB ADDRESS 15m-5 t2S1r D _CITY/ZIP C CROSS STREET e Di'/-f ffjp" :y APN !p 1 0 PARCEL SIZE • / p OWNER NAME ` k�r 'A G _'� PHONE -` by-- OWNER ADDRESS 57J Y -s CITY/STATE/ZIP y CONTRACTOR I I 1 1 GC'Gf� �c.�;k Ar'1&5-z3 C, 14► PHONE ��L✓J CONTRACTOR ADDRESS A� to7 c [V -z3 s CITY/STATE/ZIP �f'C4 LICENSE I C-42 C-36 OTHER NUMBER EXPIRATION DATE talf/r WATER TABLE DEPTH: -C" ft GEOGRAPHICAL INFORMATION: Coordinates X Y J PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: YRESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:! J ` NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG pt CAPACITY L d?8A gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE To NEAREST: WELL _ " ft FOUNDATION , ft PROPERTY LINEt ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT - ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS #OF LINES `I LENGTH OF LINES�S • ft I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Sft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It 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 It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft EEP � SAGE PITS NUMBER ` WIDTH 36 rl ft DEPTH VU 0 It DISTANCE TO NEAREST WELL l SIt ft FOUNDATION �75' ft PROPERTY LINE _S� 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. MINIMUM 24 HOUR A E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE �X5-A f-t Cc-'ILdI� DATE D' EP11--- ARTMENTAISE CINI.Y Application Accepted By Dat l Area Employee ID#� Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PAYMENT- PE SC Received Ch Amount Date Permit/ Invoice# Permit ID# Code INFO Cash Remitte Service Request# 3 0-1 -( 0 C)l S I SAY JOAQUIN COUNTY HEALTH DEPARTMENT 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17