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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT F '/ Sl,kN JOAQUIN 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 ZCROSJOB ADDRESS CITY/ZIP ow12- CROSS S STREET �1 1�� 1 1`l'U'+":� �CvofAPNr /�ARCEL SIZE OWNER NAME J a ! YH NE '1,p��j,��/1Q 1Q 73-24-2 A OWNER ADDRESS n� ^' I CITY/STATE/ZIP vv-p- `1'► l r CONTRACTOR 1 l ' '�lJ\�V� V_y 1,�/ C PHONE C ~gyp^ CONTRACTOR ADDRESS 1 I ��V ` 1 1 V�G. !Y SVI -sr-S�G)CITY/STATE21P V v LICENSE l I C-42 11 C-36 OTHER NUMBER AIF )EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y Ll PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIG ED/ALTERNA14YE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: Li RESIDENCE LJ COMMERCIAL ❑ 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 It 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 It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE To NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It 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. MINIMUMN46UR ADV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 9yy5��3-7697 SIGNED TITLE zI�_]tJiL OF rtiF C�Yv�� yifr' I !�I-�M'lp at D ARTME W IJ S E Oh 1,,Y Application Accepted By Date Area Employee iD#1A/rte Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil t?,Depth of 3 Ft: PiwSump Soil Character: COMMENTS (� Yv (S• IKLc PE SC Received Amount Date Permit/ Invoice# Permit ID# Code INFO Cash Remitted Service Request# {Zt`46_7 42-01 v ��{i� ?�O ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 /l