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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOA614 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 Nm -REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS CEX_PIRES 1 YEAR FROMDATEISSUED JOB ADDRESS ac) �rS _ OC CITY/ZIP�V Lvl�O CROSS STREET &-c- p _ _ APN `' 12-OG 1 PARCEL SIZE �•y I o OWNER NAME ! l� 1 �lyl\�`� I� _ 'n `L� A PHONE_Q� -..I `��- I 3 � OWNER ADDRESS I /O I SI elr"" • _ p' I vc CITY/STATE/ZIP G� C6, i C, CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP _ LICENSE LI !C-42 LI C-36 OTHER _ NUMBER _EXPIRATION DATE___ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y F77PERC TEST # BUILDING PERMIT# (/t/2 LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE Ll COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: c NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: L3 SEPTICTANK TYPE/MFG T_ S I /N7 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) 2N LEACH LINES C! LEACHING CHAMBERS #of LINES LENGTH OF LINES D ✓ It DISTANCE TO NEAREST WELL It FOUNDATION f ft PROPERTY LINE '� ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE 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 It ❑ 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 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 24 HOUR ADVANCE NOTICE REQUIRED FOR! P CTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE _ DATET9' IVT Eu 0 A E VI UN7Y EA D PA ENT PARTMENT 1JSdOAQY Application Accepted By. Date Area Employee ID# Final Inspection By tate ❑ SPE IAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS (0 1 L, Q,r o f -F o r 'I 1 � C o CsL e ILL PE SC Received ec Amount Date Permit/ Invoice# Permit ID# Code INFO B as Remitted �j Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 /