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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 Z 6q f CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �'r LI� CITY/ZIP CROSS STREET +1APN ZSS—QZO / PARCEL SIZE` • C OWNER NAME � �N / ✓��JU/'Vr PHONE ��J OWNER ADDRESSM? ' FJ f� CITY/STATE/ZIP / (� CONTRACTOR p r I. 'L+�.S Q L��L PHONE �S� 4'S CONTRACTOR ADDRESS 60;4 45a CITY/STATE21P Y°M �Z5o4�--ec A i�+t �J✓�lCl LICENSE , I C-42 IC-36 OTHER.�,1 NUMBER (✓ SH EXPIRATION DATE V�V WATER TABLE DEPTH:` s t GEOGRAPHICAL INFORMATION: Coordinates X Y 11 PERC TEST # BUILDING PERMIT# AND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION R AIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: r RESIDENCE 1 COMMERCIAL OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: —3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG P4-L CAPACITY 1 D oo gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY ^^ gal #OF COMPARTMENTS /of n-+- TO NEAREST: WELL `- Q ft FOUNDATION n, ft PROPERTY LINE 7� it ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) (B- LEACH LINES I i LEACHING CHAMBERS #OF LINES LENGTH OF LINES f00 ft DISTANCE TO NEAREST WELL 1`` 50 ft FOUNDATION !2-n f ft PROPERTY LINE S f * ft ❑ FILTER BED WIDTH ft LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINpE ft ❑ SUMPS WIDTH it LENGTH ft DEPTH �'( it DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY I-I VEU it ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH A R ® 0 ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPER N it U/N C Al T— it ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ENV►8.,.._ „_ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYYLL1N�� NTA 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 H U ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 c SIGNED TITLE L-�7�- '�- ✓� DATE 4!j k DEPARTMENT USE j6NLY Application Accepted By Date Area Employee ID4 Final Inspection By r�8 #/n Date /D I I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS i ov PE SC Received 4heAmount Permit/ Code INFO B ash Pernitted Date Service RequestInvoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17