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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 2f09 p 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rl N Cf, 6 Y' � I I Jt)B ADDRESS 7J� CICITY/ZIP ' r-yALU CROSS STREET �7�2 I 1 APN 2 ! —1 �� PARCEL SIZE d � L7 U OWNER NAME p�q.1 ' PHONE 0�, OWNER ADDRESS ! J �l 1-1 C- 1J'rA),LM CITY/STATE/ZIP CONTRACTOR ei5 PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE U IC-42 I-II IC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y _I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESI ED IALTERNATI E REPLACEMENT 1 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: I_I RESIDENCE IJ COMMERCIAL U 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 UI LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION It 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 It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 95 -76q7 SIGNED lv TITLE QW0 rVL DATE //12 a D PARTMENT SEONLY Application Accepte4Depof Date Area Employee ID# Final Inspection By Date UI SPECIAL PERMIT-Approved by Character of Soil to3 Ft: Pit/Sump Soil Character: COM ENTS 6 /9 PE Sc Received Check#/ Amount Permit/Code INFO B Cash Remitted Date Service Request#1-1/91 Invoice# Permit ID# '+Lq-1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17