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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 ./ �1 ^ CALL 209 953-7697 FOR INSPECTIONS �L EXPIR,E/S 1 YEAR FROM DATE ISSUED JOB ADDRESS T J �V, 5,4C,<!A&7Gi1T0 �� VO• CITY/ZIP 7' J19RA17 I / JGBG y CROSS STREET �f71/lQ/1/T�A APN DD/- a oo -/e2 PARCEL SIZE 0, 31 o OWNER NAME�?�_D q,41ZT>0^ RADg/G 4,�,/ PHONE 3 —,tet l y OWNER ADDRESS � G��fi�R R,A/D,D/S �- /2�L� CITY/STATE/ZIP / LTJ �/"/t ! --wL CONTRACTOR �it1�S��1 ��/V S ✓L l/%//v l PHONE Z—�(oyS CONTRACTOR ADDRESS P. ?u ct4 CITY/STATE/ZIP LICENSE IJI IC-42 ❑OC-36 OTHER /�� NUMBER EXPIRATION DATE WATER TABLE DEPTH: /y it GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST #. BUILDING PERMIT#__tX 0 , LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: FI RESIDENCE COMMERCIAL ❑ 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 It 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 It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINEA ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH PAV. -_ ft fritivT DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY ft Ll SUMPS WIDTH ft LENGTH It DEPTH �A ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY' 'E ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 018 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERGIt4EQU AI ft L3SEEPAGE PITS NUMBER WIDTH ft DEPTH HEA RoNMEWrAl ULI'N'-y ft DISTANCE To NEAREST WELL it FOUNDATION ft PROPERTY LINE TMENr 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 48H OURDVIANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE CI��L�/`��i//�IEEi� DATE LU bEPARTMENT USE ONLY b Application Accepted B Date Area / Employee ID# Final Inspection By ' Date ZO rl SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/ ump Soil Character: COMMENTS PE SC Received ec Amount Date Permit/ Invoice# Permit ID# Code INFO By- Remitted Service Request# *f 211 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17