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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT V SAN JOAQUIN C-,,IJNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS J EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS - _ Al �(7 �`/ _p _ _ CITY/ZIP _ {�F� �J q GROSS STREET i �'J w APIN ©�J �W _ PARCEL SIZE / f *f/fGS j OWNER NAME :Ca�dYtb {�1f5��A_�LZ -�C lei� 1 s 1 PHONE OWNER ADDRESS I��Q 9 -7-" CITY/STATE/ZIP �e/� ZJ Z�G CONTRACTOR �L PHONE CONTRACTOR ADDRESS CITY/STATEIZIP LICENSE F1 C-42 C-36 OTHER NUMBER EXPIRATION DATE 1 WATER TABLE DEPTH: O ft GEOGRAPHICAL INFORMATION: Coordinates X Y 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: ✓RESIDENCE ICOMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: S NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG h CAPACITY to=v __ gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL //(pt/ r ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) I' LEACH LINES LEACHING CHAMBERS /-iiCN #OF LINES LENGTH OF LINES SSS ft i DISTANCE TO NEAREST WELL /00 r f- ft FOUNDATION /D ?— ft PROPERTY LINE �� ft ❑ FILTER BED WIDTH ft LENGTH _ It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION It 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 0---SEEPAGE s DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft IG SEEPAGE PITS NUMBER J WIDTH y� It DEPTH ft DISTANCE TO NEAREST WEL VVD-/t ft FOUNDATION �C �' ft PROPERTY LINE 5 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 WORKERS COMPENSATION LAWS. 46 MINIMUMf+HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED- Gi a TITLE X V DATE�t``'' I VED oQ 2018 11Ito 01JIV N TMFNT EPARTMENT SE a(NL Y Application Accepted By Date Area Employee ID#� Final Inspection By Date y .� I SPECIAL PERMIT-Approved by Character of Soil to D pth of 3 Ft: Pit/Sump Soil Character: COMMENTS ly)sbecftok sqvilm123 fftL Lind C0 *ten tD n PE Sc Received he k# Amount Date Permit/ Invoice# Permit ID# Code INFO B Cas Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17