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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 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS r 0 CITY/ZIP I O CROSS STREET �� r�r1� Tn C n APN PARCEL SIZE p � 0 OWNER NAMES � 1L�J n PHONE OWNER ADDRESS ( to ` CITY/STATE/ZIP t' CONTRACTOR � �cEl. "1 ski Js+� PHONEJqr �p ®-�'b4 CONTRACTOR ADDRESS An CITY/STATE21P J�G'�V c1s�7 �s LICENSE C-42 1_I 'C-36 OTHER NUMBER EXPIRATION DATE 0 a WATER TABLE DEPTH: qb ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# r AND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION R PAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ESIDENCE 1 1 COMMERCIAL _I OTHER NUMBER OF LIVING UNITS: 'Q 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: a ,`SEPTIC TANK TYPE/MFG / ` CAPACITY �y gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 7 DISTANCE TO NEAREST: WELL :�:7 z It FOUNDATION J 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'FILTER PROPERTY�INE ft TER BED WIDTH '101' ft LENGTH �1 j f ft DEPTH I�C f ft DISTANCE TO NEAREST WELLll nO 4' ft FOUNDATION ft PROPERTY LINE i 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 NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. MINIMUM 48 Uoffl ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE AkLC=LJLO DATE E N IR N TY H EFPMINT RVA EPARTMENT S N Y Application Accepted By Date Area Employee ID# k~ Final Inspection By 41 1 1Zd4,Zj Date 2 G I i SPECIAL PERMIT-Approved by Character of Soil to Dbpth of 3 Ft: Pit/Sump Soil Character: COMMENTS Jor is V PE SC Received Check#/ Amount Permit/ Code INFO B Cash IlemitWd Date Service Request# Invoice# Permit ID# 42-01ov - n ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 Et' J ra" �� L/