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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SANJOAOUIN 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 ��l� �" ��lo _ }� CITY/ZIP CROSS STREET APN ©J PARCEL SIZE v A OWNER NAME VA\1 14N -O / !lP,H�OONEE�{ /n, //A� OWNER ADDRESS CITY/STATE/ZIP ✓ L /�/1%(—L�/c ! A V/ 5-Z CONTRACTORj/�] (� ��A �aC� PHONE CONTRACTOR ADDRESS �L7�~ter CITY/STATE/ZIP LICENSE 2:.0-42 F. C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: I'/o I 1 -L O ft GEOGRAPHICAL INFORMATION: Coordinates X Y J PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 414--RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY 931 #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) 01 LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES Cl ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft 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 J' ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PR,,OP,ERRTY LINESa►. 17 Zit SEEPAGE PITS NUMBER WIDTH / ft DEPTH�5 f AAQU/N��'w_ry7fty DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINT R�MEry ff 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SANT 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. MINIUMA 2"HOUR A P NQ9 NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED / ��- TITLE � �� DATE r� 41't i Def ARTMENT US O Y Application Accepted By. Date Area Employee ID# Final Inspection By L 6D Date I VM ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: , / Pi Sump S it Character: N COMMENTS � Z / �, AIO kAC.L,'S P&MROW h4M( IDO PE SC Receivedhe Amount Date Permit/ Invoice# Permit ID# Code INFO ash Remitted Service Request# �� -i �► 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17