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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 533 CITY/ZIPCl `X52 JOB ADDRESS ^ CROSS STREET !*�as6o'"o� APIN (2 S �� PARCEL SIZE OWNER NAMEY c�1 V )CY\�(LSA.\�+ PHONE ZM 2 01 • V'112 OWNER ADDRESSS� �n�(� � CITY/STATE/ZIP `��/j -j',�C� CONTRACTOR Vy` tJ 1 C G� L�//f�l�F—\ Ocl PHONE Z aq ✓'a't `.J 1 1 CONTRACTOR ADDRESS •J;J 1`�1LlX`V C I` 1 CITY/STATE/ZIP C 52 1 l ✓Z1+1D LICENSE 11 IC-42 ❑nC-36 OTHER NUMBER 1 1 EXPIRATION DATE LV� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATIONii� 4 or REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE �( REPLACEMENT l CJS 1� OUT-OF-SERVICE SEPTIC SYSTEM I_ DESTRUCTION Ci INSTALLATION WILL SERVE: RESIDENCE 1 COMMERCIAL e� El OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: `3 NUMBER OF EMPLOYEES: iiL SEPTIC TANK TYPE/MFG � CAPACITY � gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES !LEACHING CHAMBERS #OF LINES L� LENGTH OF LINES ft /DISTTANCE TO NEAREST WELL ft FOUNDATIONC7� l�T ft PROPERTY LINE It ❑ FILTER BED WIDTH It LENGTH ft DEPTH j ft i AT DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ems,i ft L3 MOUNDED WIDTH ft LENGTH ft DEPTH IxtUfFOyFnft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE e ft ❑ SUMPS WIDTH It LENGTH ft DEPTH D 211a It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LI P�N.10 .. ft NMENTA� ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH��fR0 ��Nft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE . Q aTMEAfT ft SEEPAGE PITS NUMBER I WIDTH� Ab if ft DEPTH ft DISTANCE TO NEAREST WELL 1,0 k_ It FOUNDATION ft PROPERTY LINE �S '� 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 COMPENSATION LAWS. MINIMUM 48 UQVR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED c� - TITLE Pr-t1rCT &,Y)_�G1-(i1a DATE LA i ARTMENTIUSaf ONLY Application Accepted�y Date f Area Employee ID#� Final Inspection By Date f�/ f'' ' 1 SPE IAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS -�' oq, wpll x," 4-x r, ii - c�n ii o PE SC Received Check Amount Permit/ Code INFO By, CashRemitted Date Service Request# Invoice# Permit ID# .� - 1 �I,+y�.�Fii— ( rv�t'� ►�i�. t', ;a . c I1c_�I .c �. 42-01 1 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17