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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 4 NON-REFUNDABLE PERMIT CALL 209 ?k3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS /j CITY/ZIP C I(� l- V / PARCEL SIZE CROSS STREET APN p v 4/110 z OWNER NAME V p��,�/ DhA (� PHONE f v� OWNER ADDRESS �ZIO l i „/S I�LV�/ Y IA- J CITY/STATE/ZIP -1 flQA CONTRACTOR C� PHONE 7 iL;/,rj, f 3 CONTRACTOR ADDRESS V I ^) ^CA- O' ^ �G CITY/STATE/ZIP �U LICENSE LI C-42 I C-36 OTHER NUMBER /`� /�J EXPIRATION DATE / ( / 3'.) 1 c � Q WATER TABLE DEPTH: I�a� ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I I NEW INSTALLATION P REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: IJ RESIDENCE I I COMMERCIAL _I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 2z NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM)( It LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES 1. 0 ft DISTANCE TO NEAREST WELL '�J It FOUNDATION �� ' ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH PA ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE t ❑ MOUNDED WIDTH ft LENGTH ft DEPTH IV�Aft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH UY 200Q ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI I`.4 OII��,_ It LI DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH EA1 `MrPV7;'. n'ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE rLj1rMFT� ft ® SEEPAGE PITS NUMBER -2- WIDTH 3 ft DEPTH �1.! - ft DISTANCE TO NEAREST WELL /-S 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 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE '-fj�� DATE -7 s PARTMENT VSEyON-L Y Application Accepted By Date Area Employee ID Final Inspection By y V Date 1_1 SPECIAL PERMIT-Approved by Character of Soil to Depth Ft: Pit/Sump Soil Character: COMMENTS PE SC Receivedhec Amount Permit/Code INFO B ash Remitted Date Service Re uest# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17