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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN SOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS.' EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP Ji•..9 �� ' %� CROSS STREET APNIZA / V /� PARCEL SIZE A OWNER NAME rr c/i2 1 CUt/ 9'�(P�HOONNEE�� / ''N OWNER ADDRESS !�%Y 7 ,YY�12��I`f� CITY/STATE/ZIP A (�!L'p'_ N�Lwiyuo S� ;� CONTRACTOR CS,;��n 7 � �✓"' iyr � c . PHONE �� /�7"B7.ZJ✓ CONTRACTOR ADDRESS IE3G� -�G,LAG �% CITY/STATE2IP t I LICENSE ❑ 'C-42 I C-36 OTHER NUMBER '"7/ZS77 EXPIRATION DATE WATER TABLE DEPTH: ft 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: I I RESIDENCE ❑ COMMERCIAL / ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: y 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 LEACHING CHAMBERS #OF LINES_ � rENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE t ft ❑ FILTER BED WIDTH It LENGTH ft DEPTH it DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH P'd ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 2waft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE JGAQ ft I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDAN L tV JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENIT CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48,dOUR ADV NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7 97 SIGNED TITLE DATE G I LL I � 140 7 � EPARTMENT JOSLeONLY Application Accepted By Date Area Employee ID#� Final Inspection By Date I I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COS MENTS (( V do '1L ' r' J_ 1Y ' I '13 ") PE SC Received ec Amount Date Permit/ Invoice# Permit ID# Code INFO By_ s Remitted Service Deguest# D , * 7 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17