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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 CALL, 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ,,//��L2 %CI.TY/ZIP / y9 � 5 CROSS STREET / - APN _l/i'J✓�Tj�i ` PARCEL SIZE D' OWNER NAME PHONE OWNER ADDRESS�MI"� CITY/STATE/ZIP CONTRACTOR i1C'l //L'is�� /�(J►�,u LrvC�G _ __ PHONET �1 CONTRACTOR ADDRESS J t'1�?v _ -CITY/STATE/ZIP _�/ 41".4 12�1� LICENSE '_ C-42 ❑I C-36 OTHER NUMBER � EXPIRATION DATE -may �y, WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION PERC TEST # BUILDING PERMIT # TYPE OF WORK: ❑ NEW INSTALLATION EPAIR/AD Coordinates X Y_ LAND USE APPLICATION # IN LI ENGINEER DESIGNED ❑ REPLACEMENT LJ OUT -OF -SERVICE SEPTIC SYSTEM IJ DESTRUCTION INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL 1 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 5 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP TERNATIVE CAPACITY _ gal # OF COMPARTMENTS CAPACITY _ gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft . ❑ 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. M!y"$A0UR4RVA NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE 45� DATE '� z CD PARTMENT U E O L Applicati n AccepteApoth Date_ Area Employee ID#� Final Inspection By Date �_! -� ❑ SPE IAL PERMIT Approved by Character of Soil to f 3 PiUSump Soil Character: COMMENTS A"u4A<oy," !xz- M-1:= <cyL— &z 7PS PE LEACH LINES LEACHING CHAMBERS /0 # OF LINES _� LENGTH OF LINES ft Amount DISTANCE TO NEAREST WELL s ft FOUNDATION ll�f-v ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1ASUMPS WID-rH -2 - ft LENGTH Lb ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER Y LINE rj ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE ToNEARC'.T Wl _L ft FOUNDATION _ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M!y"$A0UR4RVA NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE 45� DATE '� z CD PARTMENT U E O L Applicati n AccepteApoth Date_ Area Employee ID#� Final Inspection By Date �_! -� ❑ SPE IAL PERMIT Approved by Character of Soil to f 3 PiUSump Soil Character: COMMENTS A"u4A<oy," !xz- M-1:= <cyL— &z 7PS PE SC Received Chec Amount PermiU Invoice # Permit ID# Code INFO B ash emitt d Service Request # �Dja�te, 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17