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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-REFUNDABW PERMIT CALL ,2x09 953-7697 FOR INSPECTIONS �' EXPIR �ES ,Q1 YEAR FROM DATE ISSUED JOB ADDRESS 1 / 1-1-7 1---it-L A? lea CI/TY//ZIP r��Il V'� 1 4: 15-33C, � _� �r 1013 (*r L12-4 APN 4 '�{ `O C PARCEL SIZE CROSS STREET i OWNER NAME b /1 "A S r r 1 PHONE y OWNER ADDRESS 4hm%—:- CITY/STATE/ZIP CONTRACTOR Y n a'IA4L SS N Nl- // PHONE ]+O 6 ox (i'TO CITY/STATE/ZIP �l�'�+r-i+} L' •S JR` CONTRACTOR ADDRESS � LICENSE F! C-42 11, C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I I NEW INSTALLATION EPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE XREPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE i I COMMERCIAL 1.1 OTHER NUMBER OF LIVING UNITS: ! NUMBER OF BEDROOMS: 2 NUMBER OF EMPLOYEES: 11" SEPTIC TANK TYPE/MFG P+L CAPACITY 0015 gal #OF COMPARTMENTSy� ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL 4�fft FOUNDATION .j r ft PROPERTY LINE 5 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ,LEACH LINES I I LEACHING CHAMBERS }- #OF LINES/ 3 LENGTH OF LINES $Or ft DISTANCE TO NEAREST WELL I OCN i ft FOUNDATION I 1 ft PROPERTY LINE _�i It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ^'y,.. ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH Jyed ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Ij '' "ft ❑ DISPOSAL PONDS WIDTH _ ft LENGTH ft DEPTH t 7 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY 9141Y "j ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH N�E,NT,`!'y Cod, _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE�H OCP AC 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 48 t.104 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 95,7-7697 SIGNED TITLE DATE C IN :!a r EPARTMENT SE ONLY Application Accepted By Date Area Employee ID#� Final Inspection By Qd�(�^ Date / El SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/SumpSoil Character: COMMENTS O 6 H u PE SC Received Kdheck Amount Ffermit/ Code INFO B s emitted Date Service Request# Invoice# Permit ID# 0 3 a0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17