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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 11168 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT ��p CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEA FROM DATE ISSUED JOB ADDRESS �, �G A y._ — CITY/ZIP 1 m CROSS STREET; >J r rl � In - APN to 3 A 90 �I PARCEL SIZE I. 4 6 p OWNER NAME 1�i 1 Yr�1 ttc _ 1 -m A �� PHONE C I - l 0 OWNER ADDRESS 1�1 V� l�� CITY/STATE/ZIPC,� CONTRACTOR PHONE CONTRACTOR ADDRESS -------CITY/STATE/ZIP ,LICENSE ❑I C-42 n' C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# - Dy ['LAND USE APPLICATION# TYPE OF WORK: X NEW INSTALLATION i I RFPAIR/ADDITION i i ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT L; OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE L COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG PI, L CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _ CAPACITY 00 gal #OF COMPARTMENTS L DISTANCE TO NEAREST: WELL O j' ft FOUNDATION S 'k ft PROPERTY LINE 10 4 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) �1. LEACH LINES ❑ LEACHING CHAMBERS #OF LINES 3 LENGTH OF LINES ft DISTANCE TO NEAREST WELL 2-00 ft FOUNDATION `s� ft PROPERTY LINE S f ft ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH _ ft LENGTH __ ft DEPTH. ft DISTANCE TO NEAREST WELL ft FOUNDATION ov ft PROPERTY LINE ft SEEPAGE PITS NUMBER WIDTH, � -'ft' DEPTH a'5 ft DISTANCE TO NEAREST WELL 2h G I' ft FOUNDATION 0 ft PROPERTY LINE S r 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953--77697 SIGNED IL ; _ _ __ TITLE l 1W1 IeV �' 'L DATE �- ! - :NVIMIJ PIPM DEPARTMENT USE ONLY ) '�A Application Accepted ByLDate^ l—( - Area L� Employee ID#_ �+� Final Inspection By + Date —z ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS OF --U0r qkc, (/t.8'S__ 10___ `.� - A � ��UT 7° T309"s �sr _ _ IF PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# �� ►� lid 1 s s i I� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 515/17