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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ft.SAN-JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT p, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSY� ��..`�) /CCITY21P �J�� - CROSS STREET W 7 ( 1 ' ` r �� L/ APN(=kl! l PARCEL SIZE i y c z OWNER NAME J ` ��J' PHONE s OWNER ADDRESS S A P,, 6 M� "N r?' -CITY/STATE/ZIP CONTRACTOR V�I�S I ��J �.�{�c } C �� PHONE CONTRACTOR ADDRESS1 � CITY/STATE/ZIP_ V�� L`/ ✓ �V 1(�l LICENSE !_I C-42 C-36 OTHER NUMBER g��15 EXPIRATION DATE WATER TABLE DEPTH: O t ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE L_'; COMMERCIAL I_i 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 ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <' -- ---- -- ------...... ......... _.... ...-....... _ ❑ LEACH LINES X LEACHING CHAMBERS f N r t(�f J, #OF LINES �_ LENGTH OF LINES '° ' ft DISTANCE TO NEAREST WELL V406 P ft FOUNDATION 0 ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft r` DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft Cy ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft �+ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft �Q 0, SUMPS WIDTH ft LENGTH 117— ft © , DEPTH 1+ ft DISTANCE TO NEAREST WELL 5,3 ft FOUNDATION ft PROPERTY LINE S 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 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 COMPENS%AON LAWS. MINIMUMXHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED - TITLE - �_rtSV�i^J DATE 1 2.• lu 1 0 I g T b Ek A R T M E N T U E U LY Application Accepted B Date _ qq Area Employee ID# b Final Inspection By ( Date 0 ! SPE IAL P RMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS Z� PE SC Received Check#/ Amount Permit/Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# s__ oa 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17