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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 f �9 CALL 209 953-7697 FOR INSPECTIONS EXPIRE S 1 YEAR FROM DATE ISSUED JOB ADDRESS �� ( �I 4- �'r CITY/ZIP �� 7 y CROSS STREET </ a L E- A P N / �/ PARCEL SIZE004 d d a OWNER NAME `%)+C O PHONE vm OWNER ADDRESS `C�;�J�/VI G/ CITY/STATE21P / ^� CONTRACTOR .G e I l T/ t PHONE X41 -��.0 1. UVb /�j CONTRACTOR ADDRESS ��ICe �l `'�` �Y CITY/STATE/ZIP eed.; ,,A %S c3�•� LICENSE 1 I C-42 1 I i C-36 OTHER NUMBER 7��TSI EXPIRATION DATE ~J"' - WATER TABLE DEPT / ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATIONREPAIR/ADDITION I ENGINEER DESIGNE D REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION INSTALLATION WILL SERVE: ➢C RESIDENCE Ll COMMERCIAL _ 1 OTHER 9 NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS' NUMBER OF EMPLO ❑ SEPTIC TANK TYPE/MFG el_� )Wsh CAPACITY gal #OF COMPA ftNMENT ❑ GREASE TRAP TYPE/MFG IJ CAPACITY gal #OF COMPARTMENTS ""r DISTANCE TO NEAREST: WELL it FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ` / 'J LJ LEACH LINES LEACHING CHAMBERS/� (_IV,* L7�rJ #OF LINES LENGTH OF LINES 7 o xft DISTANCE TO NEAREST WELL ?4146i,0'C_ ft FOUNDATION aO 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 ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH C ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft✓� FOUNDATION a5 ft PROPERTY LINE ft L3 DISPOSAL PONDS WIDTH 0 ft LENGTH OL*z ft DEPTH 1�' ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL V C 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 209 953-7697 SIGNED TITLE DATE I y. I, 0 x 241 1� 'C 1�+ I AJ i� V U M EPARTMENT USE N Application Accepte4Dept Date Area Employee ID#� Final Inspection By Date L SPE AL PERMIT-Approved by Character of Soil tof 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received CGhacXlI1r Amount Date Permit/ Invoice# Permit 1D# Code INFO Cash emitted Service Request# a�l� � ; v 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17