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It 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 n EXPIRES_1 YEAR FROM DATE ISSUED JOB ADDRESS CIT /ZIP �� prx�I G'T! CROSS STREET fl 0 to �2 T✓ APN PARCEL SIZE p OWNER NAMEUlm / PHONE OWNER ADDRESS /C/ L&E CITY/STATE/ZIP CONTRACTOR YI 1 1 S ��fC*cL t 5 PHONEyl S , T4- ,S- CONTRACTOR ADDRESS P[� ny �� CITY/STATE/ZIP 111k'40et.+ /e4 LICENSE I I IC-42 I II iC-36 OTHER NUMBER EXPIRATION DATE o D-0 A 1 WATER TABLE DEPTH:df'nV ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: LIAESIDENCE LI COMMERCIAL I OTHER NUMBER OF LIVING UNITS: ' NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY 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 I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft e-I � "t FILTER BED WIDTH I'a ft LENGTH _x-id I�ft DEPTH ROf ft DISTANCE TO NEAREST WELL (,-Jai ft FOUNDATION if�'!, ft PROPERTY LINE �I ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH �y ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINED ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH- APR n t: [a..J)",. ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTx��N�E -" ft El SEEPAGE PITS NUMBER WIDTH ft DEPTH y 1 JOA IN CO(lly f ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERi46AI[ , nnr NTAL ft 77- RT I HEREBY CERTIFY THAT 1 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 HDKR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 �y SIGNED 64 111-- TITLE Conn+a&-4-i r DATE b ETI A IPEPARTMENT (OSEIONLY Application Accepted By Date Area Employee ID# Final Inspection By Date I i SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS T�/�—� // �r'E � � I gA42 t S 14-/ lr[� PE SC Received h Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17