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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAv JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP _ y CROSS STREET A P N IJCt ^ 1 (�P�ARRCEL SIZE �1L�`� OWNER NAME �� c, , PcH�ONE�f^�'7 10)() L4 ` 1 P OWNER ADDRESS i'J�1 1 '� I1/ CITY/STATE/ZIP CONTRACTOR )� '�/�'� �� 7CV G PHONE l�-�✓/ Z / L� �L�� CONTRACTOR ADDRESS /� �/�//"'�t✓c J/ if CITY/STATE/ZIP LICENSE K C-42 ❑LIC-36 +OTHER NUMBER DATE Q - WATER TABLE DEPTH: p ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: XRESIDENCE ❑ 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 ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 'A LEACH LINES LEACHING CHAMBERS Vj i 1) 1 I #yOF LINES LENGTH OF LINES �l ft DISTANCE TO NEAREST WELL 'ft FOUNDATION ID ft PROPERTY LINE T ft LlFILTER BED WIDTH ft LENGTH fi ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TON ARE T WELL ft FOUNDATION ft PROPERTY LI ft SUMPS ` / ft LENGTH / ft DEPTH Al ft DISTANCE TO NEAREST WELL � {t FOUNDATION ft PROPERTY LINE ft 4/i-� ❑ DISPOSAL PONDS WIDTH ft LENGTH :f 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 COMPENSATION LAWS. MINIMU 48 R VAN E N CE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-769J7��J SIGNED TITLE / ' � _ DATE v S � 4 I .� E N Cc UN 1 T 4iw-W AC DEp DEPARTMENT USE ONLY , L / �• f Application Accepted B Date lI 0/'IF � Are t' [ ��t Employee ID# >N.K I^ - Final Inspection By n Date Ll 1 `ISI N/ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS IUB �t'• InS�'t'Lf��1; cisvl�,'r,"► �1,cfa21( e- -to W 412kxl vt 'y/s : 'q3It9TrrASer� i� g- g en e,&MJ( "1) i Ve PE SC Received Check#/ Amount Permit/ Code INFO B Cash Remitted Date ervice Request# Invoice# Permit lD# 7 d ( 42-01 /"b 6" ` �� / �� O SITE�WATE TM Yj/M?7RMIT 5/5/17 ,/' /'`t U� - GIIVk-(�Iry�.�n V