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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-REFUNDABL ,E PERMIT GALL ZUY 9b:i-/69/ FOR INSPECTIONS tXPIRE5 I if EAH hHL)M UA I t ISSUtI JOB ADDRESS �� Li:i wG�/ �i1i�1 k4C) CITY/ZIPf'! IIA,,) C ch- CROSS STREET z µ G AAPN - A w- j 2 PARCEL SIZE OWNER NAME _ e-1- & % )CI v PHONE OWNER ADDRESSZ-4�1 , ___ _ CITY/STATE/ZIP CONTRACTOR � rn 4C �C nye-- C PHONE CONTRACTOR ADDRESS f �� ld a� CITY/STATE/ZIP LICENSE 11 C-42 11 C-36 OTHER -A NUMBER "r EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y_ D PERC TEST # BUILDING PERMIT # _ LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED I I REPLACEMENT CI OUT -OF -SERVICE SEPTIC SYSTEM ! DESTRUCTION INSTALLATION WILL SERVE: --RESIDENCE Ll COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG CAPACITY TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION _ SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ LEACH LINES ❑ LEACHING CHAMBERS TERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES _ _ LENGTH OF LINES 171 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 PAOUR ADVANCE NOTICE REOU!RED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE !on!ts� 24;. DATE ( 1 13 C77 LJ EPARTMENT SE NL Application Accepted By Date Area Employee ID#A&V" Final Inspection By Date SPECIAL PERMIT - Approved by Character of Soil to Depth 3 Ft iz Pit/Sump Soil Character: . COWENTS-�� 1.46 / I/i/Ma444 PE DISTANCE TO NEAREST WELL Itt FOUNDATION Date ft PROPERTY LINE ft FILTER BED WIDTH i�Jl ft LENGTH aq �j ft DEPTH Ifft DISTANCE TO NEAREST WELL Si c It FOUNDATION 101 ft PROPERTY LINE S + _ it ❑ 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 it FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I] SEEPAGE PITS NUMBER WIDTH _ ____.ft DEPTH ft DISTANCE TO NEAW: ; WELL _ ft 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. MINIMUM 24 PAOUR ADVANCE NOTICE REOU!RED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE !on!ts� 24;. DATE ( 1 13 C77 LJ EPARTMENT SE NL Application Accepted By Date Area Employee ID#A&V" Final Inspection By Date SPECIAL PERMIT - Approved by Character of Soil to Depth 3 Ft iz Pit/Sump Soil Character: . COWENTS-�� 1.46 / I/i/Ma444 PE SC INFO Received B he ash Amount emitted Date Permit/ Service Request # Invoice # Invoice Permit ID# �j 77 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17