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ONSITE WASTEWiYTER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 2009 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I Cp 3 3 s�h'Ih'Iez r /GOC/ CITY/ZIP ` G y CROSS STREET --W''''^^ ►�Q J�C��1 APN yP,ARCEL SIZE �jrz p OWNER NAME �r, �/ T�/1) PHONK��n11 _l OWNER ADDRESS I / CITY/STATE/ZIP CONTRACTOR / V C� PHONE O i / `,� CONTRACTOR ADDRESS �3/ /SAH Dir�� / CITY/STATE/ZIP C clwl LICENSE 1 IX-42 -I I_IC-36 OTHER NUMBER L15FO S EXPIRATION DATE 7 -J/ rte" WATER TABLE DEPTH: // It GEOGRAPHICAL INFORMATION: Coordinates X Y F1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION -r 5 f�I1 1 INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL _ OTHER K NUMB �// ER OF LIVING UNITS: _L NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG f^P/ CAPACITY /CY�D gal #OF COMPARTMENTS U GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL /00 It FOUNDATION 5 ft PROPERTY LINE 35 ft LIFT STATION SIZE -500 TYP&OF PUMP ❑ PKG TX PLANT L3SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES Q LEACHING CHAMBERS 6YI�SA"?j #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LlN C ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH RECEIVE® It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH._N 1 1 2019 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH SAN JOS A ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIVMtI TSH DEPARTMENT 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 WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697p SIGNED TITLE / DATE — �— / X 44 W H N 1 I EPARTMENTUSE NLY Application Accepted By Date Z,0q Area C Employee ID# ' vl Final Inspection By Date I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS0[liLt,Q-r"1 PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# A4� 122 3 UU 'Z 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17