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• ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT T CALL 209 953-7697 FOR INSPECTIONS -EXPIRES 1 YEAR FR/OM DATE ISSUED ` JOB ADDRESS J✓��h"' CITY21 %s�32 CROSS STREET 34, 9,9 APN �S �� PARCEL SIZE �" 11WNER NAME !�(/�� j'VIVG PHONE OWNER ADDRESS 'SI'l�J� CITY/STATE/ZIP CONTRACTOR �e/lf�� C��Ci PHONE CONTRACTOR ADDRESS �/(� �S'fJrn 1 �� CITY/STATE/ZIP LICENSE 142 I IC-36 OTHER NUMBER -z7J7y��EXPIRATION DATE Q� 1 1 WATER TABLE DEPTH:�V ft GEOGRAPHICAL INFORMATION: Coordinates X Y F I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I I NEW INSTALLATION YN REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL OTHER NUMBER OF LIVING UNITS: �� NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFGCAPACITY 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 AW 10 #OF LINES LENGTH OF LINES AA ft DISTANCE TO NEAREST WELL f SO 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 ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL 16W ' ft FOUNDATION MW ft PROPERTY LINE ft t1, SEEPAGE PITS NUMBER fT WIDTH 3 ft DEPTH S ft DISTANCE TO NEAREST WELL /S_0 ft FOUNDATION >O ft PROPERTY LINE So/ 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 �rSr�y O wr "0411 IN CLOL 1 • 9 NTY ENVIRCIN E4TIL JHHALTH NT E P A R TM E N TAS E.10NLY Application Accepted B Date Area Employee ID# Final Inspection By Date 4// it/Su CI SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PSoil Character: COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO A y Cash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17