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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 209 953-7697FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP 0Y�! CROSS STREET , �,, n i l`bLd'"r APN 9'Ud PARCEL SIZE ''�� OWNER NAME S? J� H L C, A PHONE OWNER ADDRESS /� �/�r �y� �/�/�p• CITY/STATE/ZIP CONTRACT OR !Q S l xl 1 '�Z�v�l/✓r iU>•/ PHONE �j /� CONTRACTOR ADDRESS AL3� I,< e f 1+ Elf. C ^� CITY/STATE/ZIP �CVQ✓24 LICENSE I I IC-42 Lh C-36 OTHER /-1 NUMBER Cl ✓I ( � / EXPIRATION DATE -2-U Z WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I I OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE I I COMMERCIAL LI OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: S NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY V gal #OF COMPARTMENTS 7- U ❑ GREASE TRAP TYPE/MFG CAPACITY r gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL f^�{� ft FOUNDATION _✓ ft PROPERTY LINE I o ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES Ll LENGTH OF LINES , ft DISTANCE TO NEAREST WELL ft FOUNDATION � ft PROPERTY LINE I O ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH It 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 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 tFOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER L 1 WIDTH6 pp ft DEPTH 7_'S ft ` J DISTANCE TO NEAREST WELL PU I+ ft FOUNDATION 1 ft PROPERTY LINE I C t ft I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 95!3-7697 SIGNED TITLE t'C4 , 8' DATE � 2i,' 777 / DEPARTMENT USE ONLY Application Accepted By �� L� Date , ;Q /( Area (� Employee IDAA Final Inspection By Z_ Date 3O ❑ SPECIAL PERMIT-Approved Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS I'JeW SFIZ, On u61ic VJA e< -1 lite NCF_ eittey- fece4e/J or )d )D 9 v -0e y PE Sc Received hec / Amount Permit/ A Code INFO B Cash Remitted Date Service Request# Invoice# # yai �i � s 8L1 gZ 1 Sqp 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17