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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT S,nN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL(209 953-7697 FOR INSPECTIONS T EXPIRES 1 YEAR FROM DATE ISSUED 2-JOB ADDRESS 7Z 7;;;-S /G!/ CITY/ZIP f�G C1 CROSS STREET /�TifIN�L-//�� /,-/7'LD APN 2 3(/�/D OZ PARCEL SIZE C d OWNER NAME /b�L�I/TE / h'lL�'/S i G PHONE �I OWNER ADDRESS / CJ O / (�STF �2D CITY/STATE/ZIP CONTRACTOR k / / �/4�� d/y� / �NL. PHONE 0 D/ —ZYy- 7-0 CONTRACTOR ADDRESS /" /JO/C �d�z6 CITY/STATE/ZIP LICENSE 1]"IC-42 I I 'C-36 OTHER NUMBER /��LY3 EXPIRATION DATE � J WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION I REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT i OUT-OF-SERVICE SEPTIC SYSTEM 29 DESTRUCTION Q OV�.IIL_ INSTALLATION WILL SERVE: I I RESIDENCE I 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 ft 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 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 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 HOUR AN EQUIRED FOR/NSP CTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE DATE / /G / All N� Z4 DEPARTMENTUSEONLY Application Accepted By Date Area Employee ID#__jr4V4_ Final Inspection By Date 6 / [J SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS <S �`z- 7�r•� �`�P' .�r.ad PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code / INFO 8 Cash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17