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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUV-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 / �� /`S L-a 1r e%A -J CITY21P_ /zae LA CROSS STREET �411 l.1NW APN Z LZ— ( �� PARCEL SIZE v OWNER NAME � ` /' �� PHONE 16130 OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR lS � ✓C �14 PHONE G 1 CONTRACTOR ADDRESS 92/0 CITY/STATE/ZIP IP7 y✓p_G�I?1QZ, - /gL A EXPIRATION DATELICENSE VIC-42 ❑CIC-36 OTHER NUMBER �y WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X_ Y ❑ PERC TEST # BUILDING PERMIT# __- LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I_I REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE Al REPLACEMENT CI OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL L OTHER �- NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: 9/'SEPTIC Al SEPTIC TANK , TYPE/MFG (iG� G/) CAPACITY ��v gal #OF COMPARTMENTS Z ❑ GREASE TRAP TYPE/MFG _ CAPACITY V gal #OF COMPARTMENTS �/ DISTANCE To NEAREST: WELL _ ft FOUNDATION It PROPERTY LINE ft LR LIFT STATION + SIZE l d! �G TYPF OF PUMP se'✓A_fr&❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TON RAST WELL ft FOUNDATK)N _ft PROPERTY LINE ft l W/ FILTER BED WIDTH ft LENGTH 110,0/ ,+� ft DEPTH -7- ft DISTANCE TO NEAREST WELL IOO t l ft FOUNDATION `f a 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 It 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 COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 n SIGNED TITLE Q DATE TA Y gip° SAA EryV U TY D P,q EPARTMENT &SE ONLY Application Accepted By Date Area Employee ID# Final Inspection By Date ❑ SPE IAL ERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: _ COMMENTS JAf0b7-g7�C7,i C0 40 iW ZZ - PE SC Received heck Amount Date Permit/ Invoice# Permit ID# Code INFO , By, Cash Remitted 1i Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17