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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 �JCALL 209 953-7697 FOR INSPECTIONS/ EXPIRES 1 YEAR FROM DATE ISSUED JLOB ADDRESS C. �� Gv G CITY/ZIP LC /�L C/ CROSS STREET J S r-Q . APN Z5" PARCEL SIZE b OWNER NAME wI 1 /!"��V PHONE OWNER ADDRESS / �• // CITY/STATE/ZIP CONTRACTOR / / PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE CJI IC-42 ❑I_IC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL I 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 It FOUNDATION ft PROPERTY LINE It ❑ LIFT STATION SIZE — _ TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES It 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 It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTHft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE r ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ' ph n ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT* _7n.- ft ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH AFLF r�a Q ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L EN/i. Ai,UN ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W AN 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)95/3--7/69c7.� SIGNED l� TITLE 9�n�-CU✓��o��'O/1 ) DATE EPARTMENT LjSE dNL Y. Application Accepted ByDate Area Employee ID# Final Inspection By f�'4�`�Q`" Date I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PiU ump Soil Character: COMMENTS !E{/� 7? _� 1 PE Sc Received Check#/ Amount Permit/Code INFO B Ca emitted Date Service Re ue t# Invoice# Permit ID# �•O 10 OW) 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17