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I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS A i1CITY21P A ; P,,i`+ -.�yT _/ s3Z o CROSS STREET _/�F-Li-U�._T�J/V APN `��' -O O/ PARCEL SIZE OWNER NAME / ��! PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR t L-t. 'ti �Y �r' PHONE CONTRACTOR ADDRESS ; ' �X ��;� rc CITY/STATE/ZIP Y • 1 r �^"r�G�j a t •) LICENSE I I IC-42 1_11 C-36 OTHER NUMBER L-1 t�7 � EXPIRATION DATE , c�) WATER TABLE DEPTH:--7 _ (J �/ ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 PERC TEST # BUILDING PERMIT# QLAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION EPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: L_Ji2SIDENCE C COMMERCIAL 1 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) a'-ILEACH LINES I 1 LEACHING CHAMBERS #OF LINES i LENGTH OF LINES ft DISTANCE TO NEAREST WELL `7 ft FOUNDATION 10 ft PROPERTY LINE 7S f— ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI 4 MENT ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH Riier+leev _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH PER L2LUI� ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE [ui ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH SAN JOAQUIN COUNTY ft ENVIKUNMENIAL DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER Etnv��r�TPT_ ft SEEPAGE PITS NUMBER WIDTH I '1 7 ,i ft DEPTHS ft DISTANCE TO NEAREST WELL f 4-� ft FOUNDATION L IS I ft PROPERTY LINE S` It 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 HOURADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 )S SIGNED TITLE <:-'JA T L' /�� f DATE1 141 ! J w, D PARTMENT LISEO L Application Accepted By Date Area Employee ID# Final Inspection By Date �.� J >' 7 I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 FF Pit/Sump Soil Character: COMMENTS PE Sc Received ec Amount Date Permit/ Invoice# Permit ID# Code INFO B ash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17