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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Cl SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIITa C�{ALL(209)/953-7697 FOR IIVSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS =717`G//+/F �1�7 CIT IP ROSS STREET APN �' PARCEL SIZE p � d z OWNER NAME A PHONE mi OWNER ADDRESS �Q CITY/STATE/ZIP CONTRACTOR oe!.��if�jJlS4�/' �` PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP '`� LICENSE 1 I C-42 1 &I_I C-36 OTHER NUMBER EXPIRATION DATE J —/7`7 � V WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y L I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WIL SERVE: f RESIDENCE i_I COMMERCIAL 1 ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: I NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG f CAPACITY gal #OF COMPARTMENTS �^ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS i DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ..............._..._______......_ ............___._._........_..___...__._____..__._..__._ _....._..___--------....__._._ 1<1 LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft l DISTANCE TO NEAREST WELL ` 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 �hIX _ ,ft .FOUNDATION ft PROPERTY LWE ft SEEPAGE PITS NUMBER WIDTH =A / ft DEPTH?/6�/ ft DISTANCE TO NEAREST WELL�ft FOUNDATION I j0'-'7? 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 COMPENSAT. ION LAWS. MINIMUM HOUR ADYANCEMOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE DATE n 110I 10�1 1 Uq r s 18 E jjEPARTME US O LY NT Application Accepted y Date Area Employee ID# Final Inspection By Date fhV/V Cl SPE AL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS CEN7j-,I $pP�:M ,�QP/1-16;V rt--_ EKISTb 16 b4 �WL D sPr ssed orh of io �i�, ew. a e PE Sc Received Amount Date Permit/ Invoice# Permit ID# Code INFO B a Remitted Service Request# 42-01 G�/ ��`�l'C w'�Z�/�� `� /dp°fly-i ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 J