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k ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN Z;OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 c NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS /EXPIIRjES 1 YEAR FROM DATE ISSUED JOB ADDRESS � r c VL V CITYIZIP �1CACV /5 3o�i H CROSS STREET A APN o2 -160-17 PARCEL SIZE C J � OWNER NAME ® L v p�A PHONE q mi OWNER ADDRESS �J �� a( iy �1� CITY/STATE21P �� ` CONTRACTOR_ CO 5—/A/C Y r-0&1- UL 7_1N G PHONE 14pf--40 Z_ CONTRACTOR ADDRESS © boy n�r 3 7 1 CITY/STATE/ZIP' /74 940ck, QCA 153,01 LICENSE 1.1 C-42 L11IC-36 OTHER NUMBER 5 EXPIRATION DATE WATER TABLE DEPTH: " ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I i REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: I; RESIDENCE F I COMMERCIAL L 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 fjAYft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH RPP% . _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �4-1 VtL6 ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH t' ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY;; ft AQUIN CO, ft LI DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH F�� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYTWTH ENTAL ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH NT 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 WORKERSC PENSATl0 AWS. MI UM 48 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-769 SIGNED TITLE�J!//L�N�/NEE _ DATE �Z EPARTMENT USE QNLY A) et" Application Accepted By Date Area Employee ID # Final Inspection By Date 2 0 F1 SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/ ump Soil Character: COMMENTS PE SC Received heck Amount Permit/Code INFO B s Remitted Date Se ' e Re uest# Invoice# Permit ID# v 3_5_1�0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17