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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS / Ja r ,{fi� CITY//ZIP � U CROSS STREET ` C r—IZLsj — v �� y' S APN O ? 02 d o b PARCEL SIZE OWNER NAME /t ,�'V _ _ PHONE �5j / ' OWNER ADDRESS /l G Z moi!/N _ —CITY/STATE/ZIP �l J� AC767 �4- 1, CONTRACTOR �� /%n /_]Cn��L✓��7V PHONE ,�� ✓ 2-9 )9 CONTRACTOR ADDRESS / y L�0 ��7 / CITY/STATE/ZIP LICENSE I I C-42 I I C-36 OTHER NUMBER C%f� nXPIRATION DATE _2_C/ G [_J WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1-1 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM ; DESTRUCTION cl It INSTALLATION WILL SERVE: 11 RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ❑ LEACH LINES 1 LEACHING CHAMBERS CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft . ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES LENGTH OF LINES 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 NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 20 SIGNED L_ / �.. TITLE �l%C DATE ft ft ft ft ft ft ft ft ft ft ft ft DEPARTMENT USE ONLY Application Accepted By -ALXDate I -� Area aq Employee ID# WU_� Final Inspection By 7 Y Date Z ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS fig01r) Q hGUSO PE Code DISTANCE TO NEAREST WELL Amount Remitted ft FOUNDATION Invoice # ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 20 SIGNED L_ / �.. TITLE �l%C DATE ft ft ft ft ft ft ft ft ft ft ft ft DEPARTMENT USE ONLY Application Accepted By -ALXDate I -� Area aq Employee ID# WU_� Final Inspection By 7 Y Date Z ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS fig01r) Q hGUSO PE Code Sc INFO Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 12 o'7S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T