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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 (SON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS L �%J W oO b j\nb�- GJ>t CITY/ZIP C A CROSS STREET Low tf S^C_ APN / PARCEL SIZE C OWNER NAME A 4 PHONE OWNER ADDRESSA5 AlADote CITY/STATE/ZIP � 8 )_( bA PHONECONTRACTOR S^ r5 CONTRACTOR ADDRESS J% /-F-wok S- CITY/STATE/ZIP ._ ✓`�Q� �� LICENSE ❑ C-42 ❑ C-36 OTHER ' ` NUMBER _IEXPIRATION DATE w l WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION f PAI ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I J DESTRUCTION INSTALLATION WILL SERVE: • L RESIDENCE ❑ COMMERCIAL 1_1 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 4NUMBER OF EMPLOYEES: 14 SEPTIC TANK TYPE/MFG `p 4-L CAPACITY gal #OF COMPARTMENTS—Z ❑ 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 Nf%%At tea✓ #OF LINES 12�1 LENGTH OF LINES 6S ' it DISTANCE TO NEAREST WELL IW% it FOUNDATION S ft PROPERTY LINE a It ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE it ❑ MOUNDED WIDTH ft LENGTH ft DEPTH it DISTANCE TO NEAREST WELL .eft FOUNDATION ft PROPERTY LINE it SUMPS WIDTH f ft LENGTH 'R � ( ft DEPTH to It DISTANCE TO NEAREST WELL 104\ ft FOUNDATION W f A ft PROPERTY LINE S it ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER .._ __ WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE it 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED __ TITLE t L� Z _ DATEAt I •ZS I ~ URNIT — --- -- � � J I TY — - -- - — NVR N EN T D ARTMENT-OSEIONLY Application Accepted y Date Area Employee ID#� V Final Inspection By I Date I N91 ❑ SPE IAL P RMIT-Approved by Character of Soil to Depth of 3' t: _- Pit/Sump Soil Character: COMMENTS PE SC Receivedeck#/ Amount Permit/ Code INFO ash Rem'fte Date Service Request# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17