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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 a Q JOB ADDRESS 1; 1 tJ� t CITY/ZIP jet o �J CROSS STREET Z'..!6fl'45 I f9 Y1 Q(3 APN LtS "61 5' v PARCEL SIZE - ` Y d O FA T a<j S. PHONE vtn OWNER NAME IF rn OWNER ADDRESS CITY/STATE/ZIP ,++ CONTRACTOR I L► L1�S 6c-uz4 �rmc- PHONE 14 � +q4 J] CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I C-42 I I C-36 OTHER A NUMBER a EXPIRATION DATE t 1 WATER TABLE DEPTH: 0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y L1 PERC TEST # V BUILDING PERMIT# il'7 i i1 LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION n ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM CI DESTRUCTION INSTALLATION WILL SERVE: 'RIRESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: t NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG tL CAPACITY 1�' J 01 gal #OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ii"rAn ft FOUNDATION. ft PROPERTY LINE 4_� ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS It OF LINES LENGTH OF LINES _ ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft FILTER BED WIDTH y ^�' ft LENGTH, t ft DEPTH I L�Sr, ft DISTANCE TO NEAREST WELL 00 ft FOUNDATION !"4 It PROPERTY LINE I`a ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It 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 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED ) TITLE j: aMn"rjet-+aT DATE 4 AEA T_ r J A UI O N tj H L D PARTMENT U SE LY Application Accepted 1:11n V3 ft , Date al�l Area Employee ID# —15Final Inspection By Date G SIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS I IF C d�fc S " PE SC Received eck# Amount Date Permit/ Invoice# Permit ID# ode INFO Remitted Service Request# 3 15 D 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17