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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUN#1'ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS n EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I n -7 aS d 1 U 4 UL' � CITY/ZIP ,1 i P O � Cyl _1 _�o�6 F �� CROSS STREET +W`7 -1 APN 9QFCI ( 00 O J6 PARCEL SIZE �d7 (> "--La� C-7- PHONES OWNER NAME OWNER ADDRESS / /7�Q / f l /J 1/ 1� t CITY/STATE/ZIP Aj_Ci C CLt CONTRACTOR __ PHONE CONTRACTOR ADDRESS __ __CITY/STATE/ZIP LICENSE [Ji C-42 ❑I C-36 OTHER_ �_!�— NUMBER _EXPIRATION DATE WATER TABLE DEPTH: I5 It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT I A O-;Z�2 G 1. LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM n DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: q NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG r L' CAPACITY 1 Cie e?5 gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _ CAPACITY A gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL S-� _. It FOUNDATION� ft PROPERTY LINE 'S ft ❑ LIFT STATION SIZE TYPE OF PUMP " ❑ PKG TX PLANT. ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS _ _ #OF LINES LENGTH OF LINES 01 ft DISTANCE TO NEAREST WELL '� ft FOUNDATION G n ft PROPERTY LINE S 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 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 COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED __ TITLE t 0`+'1't r DATE •a S16 lox 1 4ul; E N N c F T _99 /y N TMEN T U ZE O LY Application Accepted By Date Area Employee ID# Final Inspection By Date ❑ SP CAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit Sump Soil Character: COMMENTS 'j�,d .a,�,� �,li z ( A!�Lc 777 v 2., PE Sc Received a Amount ate Permit/ Invoice# Permit ID# Code INFO Cash Remitte Service Re uest# 1177 2AE 1170D. O 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17