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• ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN 40AOUIN 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 �(p 21�] (� q� I"�ON ac 1`� CITY/ZIP CROSS STREET S,�z�ss R 13 APN V 1f� 1 7 y U PARCEL SIZE ✓ p OWNER NAMEyItCfRtrZ►°t PHONE OWNER ADDRESS /NL CITY/STATE/ZIP CONTRACTOR./S T7,ye,, PHONE � CONTRACTOR ADDRESS O '7 D Y�I �� \ 1'- CITY/STATE/ZIP LICENSE I -42 1JIIC-36 OTHER NUMBER722'-ISLO EXPIRATIONDATE 0(.0/In 1/g 0 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE F1 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) LEACH LINES ,,--LEACHING CHAMBERS- ,,J,10-ft�f— #OF LINES I LENGTH OF LINES SS ft DISTANCE TO NEAREST WELL /cc I ft FOUNDATION ��'� ft PROPERTY LINE -S� 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 It 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 ft d--SEEPAGE PITS NUMBER WIDTH �/' ft DEPTH 1=- ft DISTANCE TO NEAREST WELL /s (-)Y ft FOUNDATION /C t ft PROPERTY LINE S+ 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. MINIM 48 HqWR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE e5 \ � DATE 0�,'�='/ 5 t 1 117 A16 ' LL Q� y DEPARTMENT USE ONLY Application Accepted By V Date q Area Employee ID# Final Inspection By ffiy&4KLr44YYDDate Zo! I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Check#/ Amount Permit/Code INFO Cash Remitted Date Service Request# Invoice# Permit ID# ioU 2� s uo 4P_01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17