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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 nn CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / JIArKrnCITY/ZIP v` CROSS STREET N APN (tet/[ � /N '�,/ � PARCEL SIZE SZZ. � d d (�/, OWNER NAME �J C ��QV PHO,N�E � OWNER ADDRESS L � [�� JV.) CITCITY/STATE/ZIPf1--S(R^V i CONTRACTOR�,S(� U 1♦L��c V PHONE A CONTRACTOR ADDRESS fe4 � CITY/STATE/ZIP -fVr tbc/A C11�1� LICENSE I I IC-42 I_Ii-'C-36 OTHER Q NUMBER 9 11 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y I-1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: LJ RESIDENCE CI COMMERCIAL LJ OTHER NUMBER OF LIVING UNITS: ll NUMBER OF BEDROOMS: a NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG P.IL CAPACITY ��j/6�/ gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES L LEACHING CHAMBERS #OF LINES LENGTH OF LINES K ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS C�j� WIDTH ft LENGTH '/ V ft DEPTH ft DISTANCE TO NEAREST WELLtG ft FOUNDATION ( 0) \ 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 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. 1 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 I PECT ONS-PLEASE CALL 209 953-7697 SIGNED Y.IX TITLE DATE U-13-)? T I I J / O ry C U G D PARTMENT LPSE 014 LM Application Accepted By na P1 Area Employee ID#� Final Inspection By Date LJ SPECIAL PERMIT-Approved by Character of Soilt Dept .of 3 Ft: PI Sump Soil Character: COMMENTS 1�� - PE SC Received Check# Amount Date Permit/ Invoice# Permit ID# Code INFO 1h --L—ash emitted Service Request# MO ' f5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17