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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAID JOAOUIN 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 JOB ADDRESS Q CITY/ZIP n CROSS STREETAPN.0-Y /� _PARCEL SIZE Y 0 OWNER NAME J �l C-5CAyW PHONE cl[Z "'7�j3 OWNER ADDRESS?i /�// lam/ CITY/STATE/ZIP ��,� CONTRACTORC.S� PHONE //� CONTRACTOR ADDRESS f s At!' G S: CITY/STATE/ZIP �/'/ ►' ��Ya�A� ,s LICENSE I I-C-42 I I C-36 OTHER + NUMBER EXPIRATION DATE 1. I I WATER TABLE DEPTH:�7 lO� ft GEOGRAPHICAL INFORMATION: Coordinates X Y L PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION EPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: /RESIDENCE Ll COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 9 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ---------_ . ..._...-.......... LV'LEACH LINES LEACHING CHAMBERS #OF LINES D. LENGTH OF LINES �f ft DISTANCE TO NEAREST WELL. I ;noo ft FOUNDATION_S 3 ft PROPERTY LINE S> ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft 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 FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER H WIDTH & t/ ft DEPTH As i ft DISTANCE TO NEAREST WELL I Cj:) ft FOUNDATION 'T S It PROPERTY LINE 7 5 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 24 OU DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED _ TITLE_ 75� DATE �' I I . .,D PARTMENT WSE OkLY Application Accepted By ` Date Area Employee ID# Final Inspection By Date Alzk�lk ❑ SPECIAL PERMIT-Approved by Character of Soil t Depth of 3 Ft: Pit/Sump Soil Character: COMMENTSRFnirn PE SC Received eck Amount Permit/ Code INFO B sRemitte Date Service Re uest# Invoice# Permit ID# 2.0 3 4 , AN JOAQUIN COUN HEALTH DEPMA�L�� 42-01 ONSITE WASTEWATER TRTMNT SYS M T 5/5/17