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t ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 VON-REFUNDABLE 66PERMIT ( CALL 209 953-7697 FOR INSPECTIONS EXPIRES EXPIRE�S 1 YEAR FROM DATE ,ISSUED JOB ADDRESS l -e J 1— r7 CITY/ZIP r ';0 .� /7 v ✓ y CROSS STREET I �� A P N �O✓ v 1 PARCEL SIZE d �!i r.��fL- k�yl �l OWNER NAME / _._ PHONE � OWNER ADDRESS -CITY/STATE/ZIP CONTRACTOR C � �+ (iGICh",3 e, " j PHONE �� • 9��r CONTRACTOR ADDRESS �I CITY/STATE/ZIP 7-5 LICENSE Uk C-42 Lfi IC-36 OTHER o4 NUMBER d'j f EXPIRATION DATE WATER TABLE DEPTH: 0- 246' ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION EPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 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/MEG 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 LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft J—FILTER BED WIDTH k), ft LENGTH A! r It DEPTH 4? ;� It DISTANCE TO NEAREST WELL I f 0 i ft FOUNDATION ft PROPERTY LINE S ft ❑ MOUNDED WIDTH It LENGTH It DEPTH a. I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ANJO ft 'NVDISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINY' IR0;MA Mc.DIJIV7! ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH El'gTft DISTANCE TO NEAREST WELL It 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 209 953-7697 SIGNED / TITLE "C7�"A ��k �� DATE 1 � fie EPARTMENT DISE O LY Application Accepted ByDate ?i�/ Area Employee ID# OC Final Inspection By_ d2Z YIt� Date c' I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Che Amount Date Permit/ Invoice# Permit ID# Code INFO y Cash Remitted Service Re uest# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17