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C4 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT AGti SIN.:OAOUIN 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 JC.:k ADDRESS � C' �' C'N vlSz. /tCITY21P �L3Z)2RA J CROSS STREET CV t A P N a.5;- 160—7p PARCEL SIZE r O y OWNER NAME li L ��... ^V 1J '� � �� r S PHONE r J OWNER ADDRESS iC 7 1 �� CITY/STATE/ZIP CONTRACTOR J CSS t � eK�� , �+ i PHONE -7 5 L)4 CONTRACTOR ADDRESS �.� ��'`\ �� CITY/STATE/ZIP A.`J L C Ly LICENSE 11 C-42 I I C-36 OTHER NUMBER �3caitS-7 EXPIRATION DATE WATER TABLE DEPTH:1 V ��/ ft GEOGRAPHICAL INFORMATION: Coordinates X_ Y E PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION , REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE N REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DES T CTION _ INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL/per&OWWOTHE NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG Y/�.� CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft D, LIFT STATION SIZE Z TYPE OF PUMP 0!04(3 ❑ PKG TX PLANT ❑ SAND OIL SEPARAT09(ENCLOSED SYS EM) ❑ LEACH LINES )e LEACHING CHAMBERS �_�r``t'f '��_ #OF LINES LENGTH OF LINES N DISTANCE TO NEAREST WELL '1!50 ft FOUNDATION 10 .i- 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 pft ElSUMPS WIDTH ft LENGTH ft DEPTH /ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Enft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH J/ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIgA ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH JOAQU ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LILATH N&IE 141 ft T 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 COMPENS4TLION LAWS. MINIMUM- HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE_�)5t,S_j DATEIry b U i EF'ARTPAENT USE NLY Application Accepted By Date Area Employee ID#� Final Inspection By S`��`^ Date /.7//f ❑ SPECIAL PERMIT-Approved by \ Character of Soil to Depth of 3 Ft: _ Pit/S mp Soil Character: Mo � lr C ENTS �a (00 2q/) 4 ` pt e -'r. ej itl�•a!w YQf CobQf- kt . PE SC Receivedhec Amount Date Permit/ Invoice# Permit ID# Code INFO ash Remit d Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17