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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 CA_ LL (209) 953-7697 FOR INSPECTIONS _ EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY21P CROSS STREET T/ % &-z6 APN !7 n VW � 7 PARCEL SIZE 30 OWNER NAME i c-/di�/K of //L/ A PHONE OWNER ADDRESS _ _ _CITY/STATE/ZIP CONTRACTOR G,O 14 401W Ad / /4%iO/0-1VA� PHONE CONTRACTOR ADDRESS 11C 151- C� f .j Q/ f CITY/STATE/ZIP LICENSE 11C-42 ❑ C-36 OTHERR2_ NUMBER_iJO/`! EXPIRATION DATE WATER TABLE DEPTH: J V ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE IJ COMMERCIALn, [_I OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 1 Z NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG (::-a C11�_ . CAPACITY 12-49(3 gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit ID# DISTANCE TO NEAREST: WELL O C3 ft FOUNDATION L U ft PROPERTY LINE 1 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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. INIMU UR CE NOTICE REQUIRED FOR IN PECTIONS -PLEASE CALL 209 953-7697'7' SIGNED4 TITLE_ L' DATE Appiicaduri Accepted B Final Inspection By "C44 Character of Soil to Depth of 3 Ft:_ COMMENTS a DEPARTMENT USE ONLY �� L1 Data Area _ _I q ,. Employee ID#_ _-A Date FJ SPECIAL PFRMIT - Approved by Pit/Sump Soil Character: - - ---� r Pt SC Receivedne k#/ Hmowlt 2 b Permit ID# LEACH LINES ❑ LEACHING CHAMBERS # OF LINES Remitted LENGTH OF LINES O ft Service -Request #—- DISTANCE TO NEAREST WELL 100 ft FOUNDATION 1 U ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH —1 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 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 WIDTH ft DEPTH _ ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE 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. INIMU UR CE NOTICE REQUIRED FOR IN PECTIONS -PLEASE CALL 209 953-7697'7' SIGNED4 TITLE_ L' DATE Appiicaduri Accepted B Final Inspection By "C44 Character of Soil to Depth of 3 Ft:_ COMMENTS a DEPARTMENT USE ONLY �� L1 Data Area _ _I q ,. Employee ID#_ _-A Date FJ SPECIAL PFRMIT - Approved by Pit/Sump Soil Character: - - ---� r Pt SC Receivedne k#/ Hmowlt Permit/ Invoice # Permit ID# Code INFO Cash Remitted 1.Dat Service -Request #—- �l l 1 3ov —1 42-01 5/5/17 ONSITE WASTEWATER TRTMNT SYSTFM PERMIT T