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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN BOUNTY 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 N CITY/ZIPXk,0�"fLL `tz7aZc/ CROSS STREET APN,0I7-f1 O- "fa PARCEL SIZE p d OWNER NAME )qrc YY)IQW- U 1AI/I PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR �p jrf n /��v/C.L� S'�l7 C� PHONE L07 -36el- �,LU'y/ CONTRACTOR ADDRESS 6 316 DAuty 4?K- CITY/STATE/ZIP LICENSE I I�C-42 1_1 i IC-36 OTHER NUMBER ��u y 5 EXPIRATION DATEDAY WATER TABLE DEPTH:f`O' 1 W( ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1_I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGIIIE f� REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION RE mm ,/ INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLO . > ❑ SEPTIC TANK TYPE/MFG �S.4CAPACITY gal #OF CofiAb Ql o�� ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF Cclry�QIAMFNTn� DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE DCPA?TNIENT ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES I I LEACHING CHAMBERS #OF LINES_� LENGTH OF LINES �'Io ft DISTANCE TO NEAREST WELL JDO i- ft FOUNDATION � ft PROPERTY LINE I!1C ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It 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 WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL /S& r ft FOUNDATION ft PROPERTY LINE ,J(J� ✓' 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE DATE 3/i V1 Y At '44— •D PARTMEN SE O Application Accepted By t A47 Date Area Employee ID# Final Inspection By _ Date —I n SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 t: Pit/Sump Soil Character: COMMENTS ��I PE SC Received heck Amount Permit/Code INFO B as R mitted Date Servicequest# Invoice# Permit ID# 0 ( jq 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17