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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 J9� �"' (CALL 209 953-7697 FOR INSPECTIONS EXPIRE lS �1 YEAR FROM DATE ISSUED JOB ADDRESS ��V ►t-'�' 1i �I o� Ally, 'JCITY�/ryZIP �i1 l ) Ld��7 CROSS STREET a li o cJ APN `1 7 ^_2v _ PARCEL SIZE (Q/ OWNER NAME ��+�� (1 U 2 _ PHONE `� Il S OWNER ADDRESS S`� ` I o r AIy ! ' V CITY/STATE/ZIP - L� L - CONTRACTOR - PHONE CONTRACTOR ADDRESS LICENSE C-42 I C-36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X �Y T LI PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION` - ENGINEER DESIGNED /ALTERNATIVE. REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM /` DESTRUCTION a0'�L C INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL Ll OTHER NUMBER OF LIVING UNITS: \ NUMBER OF BEDROOMS: ?� NUMBER OF EMPLOYEES: XSEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY I ZOO gal # OF COMPARTMENTS` CAPACITY gal # OF COMPARTMENTS It FOUNDATION It PROPERTY LINE ft - ❑ PKG 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 It LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ ❑ MOUNDED WIDTH It LENGTH ft DEPTH _. DI N I'�ST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS p ft LENGTH It DEPTH WELL ft FOUNDATION ft PROPERTY LINE _ $ TDIST ❑ DISPOSAL PfD$VI It LENGTH ft DEPTH AJ1 DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH It 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 COMPENS LAWS. IINIMUM OU/R ADVANCE NOTICE REQUIRED FOR IN ECTIONS - PLEASE CALL 209 95 -7697 SIGNZED dSfG7u 2 JO.i / �1 n 7, TITL 61.1.E ill e Y v DA E L� -L-" - - /(1 Application Accepted By Final Inspection By Character of Soil to ept COMMENTS of 3 Ft: Date Area ❑ SPE PiVSump Soil Character: � Employee ID# IAL PERMIT - Approved by ft ft ft ft ft It ft ft ft It It It PE SC Received Check#/ Amount Permit/ Code INFO Cash Remitted Date Service Request # o' it ID# V lsA ZO S027 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 iii Y O 0