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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAW JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUN B � CALL 2 253- 97FORINSPECTIONg EXPIRES 1 Y R FROM DA ISSUED JOB ADDRESS CITY/ZIP v Y CROSS STREET I DAvc C,APN _ ��. � ✓2 O PARCEL SIZE 2 •OA7n � a v OWNER NAME ONE 6� -490-5076 OWNER ADDRESS �Q AYZACITY/STATE/ZIP CONTRACTORF PHONE / CONTRACTOR ADDRESS 4boo t 1 6j l f**� CITY/STATE/ZIP LICENSE C 42 C-36 OTHER A NUMBER Q EXPIRATION DATE PAI WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y RECEIV�p 7 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# APP i TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALT R IV REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE 11COMMERCIAL 11OTHER H CA I W9NMENra► N NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: UtPAR�ME T SEPTIC TANK TYPE/MFG Y'('�! L CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 1 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 I DISTANCE TO NEAREST WELL 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 ft DISTANCE TO NEAR ST WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH It LE TH It DEPTH ft DISTANCE TO NEAREST WELL A ft FOUNDATION I D-+ ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It 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 WORKE S COMPENSATION LAWS. M 'f- HOU AD"NtWjWjQU1RED FOR 10 S-PLEASE CALL 209 -76-47 SIGNE TITL DATE n A; r. f \ PARTMENT SE ONLY Application Accepted By Date Area Employee ID#� Final Inspection ByDate ❑ SPECIAL PE MIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS " ' 1016 x (.' Z PE SC Received hec Amount Date Permit/ Invoice# Permit ID Code INFO as Remitted ;1 Service Request# 1V"1 M 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17