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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS W .� 'S �� 7 �' CITY/ZIP 0CROSS STREET APN&7 1ZJ p OWNER NAME �C.%��[/�/✓ PHONE �n OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR `LzI S -� 1�1'� PHONE_j� /y�� CONTRACTOR ADDRESS �� , r-. CITY/STATE/ZIP d ,1 k=ff'e,,_4 .44:A LICENSE I II iC-42 IIC-36 OTHER NUMBER -EXPIRATION EXPIRATION DATE "'p6rk) WATER TABLE DEPTH:17Y ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: I 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 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTH " Y ft LENGTH ,s� ( ft DEPTH�� ft DISTANCE TO NEAREST WELL�-> ft FOUNDATION 1 3 ft PROPERTY LINE N 5 ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL 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 HQVR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE DATE l jCj d! T FLEVED 01 5A' UNTY TAL L7dH EP R MENT c EPARTMENT SE Y Application Accepted B Date 7i Area Employee ID# Final Inspection By Date C SPECIAL PERMIT-Approved by Character of Soil to Ddpth of 3 Ft: Pit/SUmp Soil Character: COMMENTS b o PE SC Received Check#/ Amount Permit/ Code INFO B Cash emitted Date Service Request#LSOOQ_ Invoice# Permit ID# v♦ - ` 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17