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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 CALL 209 953-7697 FOR INSPECTIONS ExPPIRlE�S 1 YEAR FROM DATE ISSUED JOBADDRESS CITY21P___-5 CROSS STREET APN PARCEL SIZE /` � �y d OWNER NAME / LU 15 PHONE � OWNER ADDRESS '7A40r1-_ ,,, -/ CITY/STATE/ZIP CONTRACTOR 1�r -'S 16-rc(C L L' PHONE Yi 9: — CONTRACTOR ADDRESS 0 CITY/STATE/ZIP �✓! 1`� fes" l�✓/` LICENSE C-42 I I C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y CI PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION i ENGINEER DESIGNED/f"11 NATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION // INSTALLATION WILL SERVE: IL,4RESIDENCE 11 COMMERCIAL 11 OTHERwc 1 i� NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: It L3 SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPANTPtENTS� ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COM�``RNN i��Q�R"e DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE THIO �MF7Nt'�uN�ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM LEACH LINES I 1 LEACHING CHAMBERS #of LINES LENGTH OF LINES �6' ft DISTANCE TO NEAREST WELL ft FOUNDATION ao 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 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBERS WIDTH �/ ft DEPTHS 1 ft DISTANCE TO NEAREST WELL ft FOUNDATION I.7t7 It PROPERTY LINE AIN? 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. 1 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 Coo-n C C3-r DATE 16l lo w 'Ib EPARTMEN SE N Y Application Accepted By Date O L Area Employee ID#11 w � Final Inspection By Datekff I SPECIAL PERMIT-Approved by Character of Soil to DeptIW3. �� PiUS mp Soil Character: / COMMENTS �I1� 'c� �,� O PE SC Received h Amount Date Permit/ Invoice# Permit ID# Code INFO Gash emitted Service Request# o � �lo-I S�Z00 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17