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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 1 NON-REFUNDABLE PERMIT CALL209 953-7S 97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 0 �- CITY/ZI s CROSS STREET - APN ^ PARCEL SIZE `�• p OWNER NAME i !-i�p �L- C�rNG H�-�1 PHONE OWNER ADDRESS - Ll/y"qy F G, CITY/STATE/ZIP I oC'( /'�� 2,3 CONTRACTOR CONTRACTOR O 7� PHONE t—( r 2,3 CONTRACTOR ADDRESS _ CITY/STATE/ZIP LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#_ ___ TYPE OF WORK: NEW INSTALLATION R AIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE If_: COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMFG _ CAPACITY gal #OF COMPARTMENTS Q GREASE TRAP TYPE/MFG,,'L' '5,2 IJ _ CAPACITY X-:;D gal #OF COMPARTMENTS. 7- DISTANCE To NEAREST: WELL �.y L t (t FOUNDATION -- -__ (1 PROPERTY LINE It ❑ LIFT STATION SIZE _ TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENOL SED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST `.HELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH _ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH _. ft LENGTH _ It DEPTH ft DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH __ ft LENGTH _ _ ft DEPTH ft DISTANCE TO NEAREST WELL. It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER _- WIDTH _ _ft DEPTH _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 CO NSAIION LAWS. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 SIGNED _ TITLE wN-4\ DATE D79 /V .N &Y,TI I F _ 1 H F Oi8V p - L � M ( 1 - leg WE TMENT SE O Y Application Accepted By Date Area _ Employee IDN� Final Inspection By Date CI SPECIAL PERMIT-Approved by Character of Soil to Dept of 3 F. Pi ump Soil Character: COMMENTS U t _ �j :C� -- — ` PE SC Received Amount Permit/ y, Date Invoice# Permit IQ j Code INFO B ash _emitted Service Request# I t2l 42-01 ONSITE WASTFWATFIi TRTMNT SYSTEM PERMIT 511.5/17