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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 ISSUE[ JOB ADDRESS W (A./'iI'CITY/ZIP �f eiC ;�•7'0 CROSS STREET �1" I �/J 1 _ APN/ " "/ Vi/ (/� PARCEL SIZE OWNER NAME_ _Lil L L4�, PHONE {� OWNER ADDRESS Pri t r C R CITY/STATE/ZIP Lf -f �e /� 4 �J 3L -)- CONTRACTOR IkL' Aac4c Ze it PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP 41-G 3j., LICENSE I I C-42 I I C-36 OTHER NUMBER EXPIRATION DATE LP') ] WATER TABLE DEPTH:'" ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT #� TYPE OF WORK: NEW INSTALLATION V REPAIR/ADL Coordinates X Y LAND USE APPLICATION # REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: Q�ESIDENCE 1 COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: .L- NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT TERNATIVE gal # OF COMPARTMENTS_ gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ 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 COMPEN�ION LAWS. NOTICE REQUIRED FOR INSPECTIONS - SIGNED _ TITLE ,rt'LC 4 '3 DATE Application Accepted By Final Inspection By� Character of Soil to Depth of 3 COMMENTS T M E N T 10 SE LY Date Area Employee ID# Date ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE Code LEACH LINES LEACHING CHAMBERS Check#/ Cash # OF LINES Date LENGTH OF LINES ft Invoice # Permit ID# DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTH bS 1 ft LENGTH .�� ft DEPTH (D J1 ft DISTANCE TO NEAREST WELL 16Qkl ft FOUNDATION lei ft PROPERTY LINEab" 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 COMPEN�ION LAWS. NOTICE REQUIRED FOR INSPECTIONS - SIGNED _ TITLE ,rt'LC 4 '3 DATE Application Accepted By Final Inspection By� Character of Soil to Depth of 3 COMMENTS T M E N T 10 SE LY Date Area Employee ID# Date ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE Code SC INF Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 0: (G 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17