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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT �J SAN JOAOUIN COUNTY ENVIR -.NMENTAL 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 Spf�c: �c ,,A 9S2 ' y JOB ADDRESS � D �✓ CITY/ZIP e- 'Lf CROSS STREET lc A rt'A '-S � /V✓ � APN � � 7' ��'7 I PARCEL SIZE O • `T 7 OWNER NAME C-5 IAv()5A I ^WI L LZIA-kl C, 7rr PHONE 1 Q ( OWNER ADDRESS O Da 1�y'/"T 1 _( W _ CITY/STATE2IP SAa % "/ i �7i / _ CONTRACTOR `-��! c�� .7� �' __ PHONE CONTRACTOR ADDRESS —0"�, — �a S 0 CITY/STATE/ZIP 1 ► IG%di tL�-� li� •g 3 LICENSE E C-42 ❑ C-36 OTHER NUMBER `F' 5S EXPIRATION DATE ( ! T1 WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # I BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION L.REPLACEMENT LAND USE APPLICATION # OUT -OF -SERVICE SEPTIC SYSTEM ' i Y ENGINEER DESIGNED /ALTERNATIVE DESTRUCTION INSTALLATION WILL SERVE: Li4ESIDENCE I I COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: O' -'SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG >R�L TYPE/MFG DISTANCE TO NEAREST: WELL 50 1__— ft SIZE TYPE OF PUMP CAPACITY UP &0 S__ CAPACITY gal # OF COMPARTMENTS FOUNDATION ft PROPERTY LINE It ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) EACH LINES ❑ LEACHING CHAMBERS # OF LINES 41 LENGTH OF LINES,h5S It DISTANCE TO NEAREST WELL �� i it FOUNDATION (0 1 ft PROPERTY LINE �'� r ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE IIUVft ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINEN ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 1/Fe V/ INC ft DISTANCE To NEAREST WELL It FOUNDATION It PROPERTY LINE a pm It i� SEEPAGE PITS NUMBER_ _ _ _ WIDTH ((o r) ft DEPTH AS I 14fENT ft DISTANCE TO NEAREST WELL j _ ft FOUNDATION �di _ _ -ft PROPERTY LINE IJ i It 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 2 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED – TITLE�nI OL5 DATE ' j, Application Accepted Final Inspection By -4 Character of Soil to D COMMENTS V DEPARTMENT SEONLY Date I _ Area I lq! � _ Date Cl SPECIAL PERMIT - Ft: Pit/Sump Soil Character: i0 . i/A , / - IL1 ..!w Employee ID# VV Uri –I Approved by PE Code SC INFO Received B heck Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 0its 7 `' S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17