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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 EXPIR ES 1 YEAR FROM DATE ISSUED JOB ADDRESS A-7 T�,:[.g � CITY/ZIP ��ciy Gtr 5 3 ny � CROSS STREET �1n APN J�J_ '� � 0 a. PARCEL SIZE,2L&I OWNER NAME Du r-0-1) S� r y n_n j Q {e PHONE �7' .LTJ OWNER ADDRESS 3� CITY/STATE/ZIP CONTRACTOR AA .�fr�S �') voc', Y-f- -50to -Ce, PHONE ex '}-M�1-�5fs�� CONTRACTOR ADDRESSk, 11 CITY/STATE/ZIP Y�1'"�'�M�✓f / L'� / �3�11� LICENSE I I I C-42 I I IC-36 OTHER IRT- NUMBER EXPIRATION DATE 1 WATER TABLE DEPTH: C� ft GEOGRAPHICAL INFORMATION: Coordinates X Y I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: J-RESIDENCE F-I COMMERCIAL I OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ROOSEPTIC TANK TYPE/MFG Pi-L CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL _� •� ft FOUNDATION I.�A ft PROPERTY LINE 20,1' ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) �ACH LINES LEACHING CHAMBERS #OF LINES_ LENGTH OF LINES ivb r ft DISTANCE TO NEAREST WELL ft FOUNDATION 1 ft PROPERTY LINE /!1%1 It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE it ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Air ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH PA T AA�r..�ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE /+,ft E3 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTHto ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE APR 2rft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINAQUIN ft .._ TH FF p�� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDAN89vW 64 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE -�f-!'=--t�a'A DATE NN �J/�► DEPARTMENT USE ONLY l Application Accepted By, Date 't Area Employee ID#'V P�tnn Final Inspection By `LJA� Date .^ SPECIAL PERMIT-Approved by Character of Soi to Depth of 3 Ft: Pi ump Soil Character: COMMENT,EtM ! Cc4d h ti240-r 2-760-5 11,1-Str PE SC Received eck Amount Date Permit/ Invoice# Permit ID# Code INFO B&A Remitted Service Request# t Aq 5K 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17