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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT !4N 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 CITY IP Q— ^�I /�7 m CROSS STREET / APN /// 7-- �D PARCEL SIZE OWNER NAME PHONE t� (r� 9 5- OWNER ADDRESS ati d l ITY/STATE/ZIP �(2 CONTRACTOR (J` e5�'/^�n" aciS��p �� ` L c--� PHONE 6 > ' 5 G(' ''ll CONTRACTOR ADDRESS / , `6L K �""�� S-� ` CITY/STATE/ZIP `� _I V LICENSE C-42 C-36 OTHER NUMBER 1 EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y Ll PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALT RNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY Uri gal #OF COMPARTMENTS GREASE TRAP TYPE/MFG F 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 #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 ft DISTANCE TO NEAREST WELL It 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 It 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 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 �1 SIGNED �/` �^^ _ TITLE i�rl�w+/ CC/�'yl DATE `�-N I 1 IL I Zk. P A R T M E N T IIS Application Accepted Ay Date_ Area Employee ID# Final Inspection By Date 0 W7 SPECIAL PERMIT-Approved by Character of Soil to epth of 3 Ft: Pit/ ump Soil Character: COMMENTS f�h�enre old stc4 (" +6 V1 e� c. �, . new �g ► x PE SC Receivedheck#/ Amount Permit/ Code INFO By Cash liemitted Date Service Re uest# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17