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ONSITE WASTEWATER TIREATM ENT SYSTEM PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDAB ��L E PERRM-IIT r GALL (ZU.9) 1553-7697 FOR INSPECTIONS y� EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS 7, J �� . > n � Igo 1J 1yN _ CITYRIP r CROSS STREET V �J'� APN � 8 - r�� d PARCEL SIZEM i OWNER NAME �V fk� Nth }i [J 1� �.' PHONE(i0q — 20-(— — LJ3Z OWNER ADDRESS ��.� Lam - KJ �O7`% TiMl MAJ CITY/STA- -�(ziYLy J�'k V10 zIZ CONTRACTOR t L— PHONE CONTRACTOR ADDRESS 7 DWS ❑x�"" ��hl,� _�� LICENSE C-42 00-36 OTHER NUMBER �� !\�'i -� 5- — - CITY/STATE/ZIP �"�✓,]/tom I �J �l� EXPIRATION DATE_ II C� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 , PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATI REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM x DESTRUCTION INSTALLATION WILL SERVE: L RESIDENCE ��]] L COMMERCIAL OTHER NUMBER OF LIVING UNITS: SIE BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPF/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ITY gal # OF COMPARTMENTS :ITY gal # OF COMPARTMENTS DATION _ ft PROPERTY LINE ft TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE ❑ MOUNDED WIDTH -_ ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH _ - ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER _ WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. MI MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEAS"E" CALL 209 953-7697 SIGNED �'� TITLE -Pi7 I L -PT N�tL tl ` DATE 1 Application Accepted By yI IN Final Inspection By / v Character of Soil to Depth of 3 Ft: COMMENTS �L ) - DEPARTMENT USE GIN L Y Date Area Employee ID# Date ❑ SP IAL PERMIT - Approved by Pit/Sump Soil Character: ft ft ft ft ft ft ft ft ft ft ft ft PE SC Received hec Amount Permit/ Code INFO B ash Remitted Date Service Request #PER it ID# IT Z v 377?—?i /7 8r P.�� °o -m 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17