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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P �/r S/6N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT JOB ADDRESS CROSS STREET / v OWNER NAME._ �`/" ell OW13ER ADDRESS CC,NTRACTOR " CALL (209) 953-7697 FOR INSPECTIONS APN EXPIRES 1 YEAR FROM DATE ISSUEI PARCEL SIZE PHONE �iM� G9 ON CITY/STATE/ZIP P %- i IIA PHONE ff ' CONTRACTOR ADDRESS 1L/y / T f/�N!// �r CITY/STATE/ZIPJ-- LICENSE I _I C-42 C-36 OTHER _ NUMBER? (5 Vn EXPIRATION DATE �V r WATER TABLE DEPTH: t;U U ft GEOGRAPHICAL INFORMATION: CO;Drdl ates X Y SC INFO CI PERC TEST # ERMIT#jky_7!:j JAOZoVLAND USE APPLICATION # Check... ash TYPE OF WORK: NEW INSTALLATION Of R PAIR/ADDITION ENGINEER DESIGNED/ALTER ATI E Permit/ Service Request # REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION 00 Permit ID# INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG 1"t L CAPACITY d gal # OF COMPARTMENTS Z ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL `GiL7 ft FOUNDATION Z t7 ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) AI3 LEACH LINES LEACHING CHAMBERS # OF LINES WVWLENGTH OF LINES �J ft DISTANCE TO NEAREST WELL �� f ft FOUNDATION ft PROPERTY LINE - ft ❑ 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 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 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 2 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED DATE 3�r% Lead 4y - .00 r" U � T FNl NEPARTMENT1JSEkNkY Application Accepted Date Area Employee ID# 14A��/ Final Inspection By Date❑ SPECIAL PERMIT - Approved by Character of Soil to D th of F A 19 Pit/Sump Soil Character: COMMENTS �X'1% �? .,� -T M ✓ O l�P PE Code SC INFO Received B Check... ash Amount em' ed Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17