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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ,9P,,N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 WON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED IcaADDRESS ( 501 t4`NahES-rL .0 L^N L CITY/ZIP (fit. CCROSS STREET L- > � APN VF�`" O _PARCEL SIZE Ci Ql 1 p bAf OWNER NAME PHONE OWNER /� OWNER ADDRESS 7A�,�1�S r `div /PO3�J CITY/STATE/ZIPW7 C`/�(V �CA CONTRACTOR "CW`�` `.i��CK`�v�' �I�I PHONE � ? CONTRACTOR ADDRESS J in t l.--j�1( S CITY/STATE/ZIP V -L CA 1115`V0 l LICENSE I I C-42 I C-36 OTHER A NUMBER 5�7 EXPIRATION DATE -t WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: CODrdin es X Y G1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# 3 TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE (- REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: E$-RESIDENCE ❑ COMMERCIAL ❑ OTHER r' NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Z NUMBER OF EMPLOYEES: v ❑ SEPTIC TANK TYPE/MFG &� CAPACITY 1Z VV gal #OF COMPARTMENTS 2 y( ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal #OF COMPARTMENTS y DISTANCE TO NEAREST: WELL ft FOUNDATION �' ft PROPERTY LINE -J ` ft �. ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS 1 r.4 #OF LINES_� LENGTH OF LINES v S ft DISTANCE TO NEAREST WELL I'U ft FOUNDATION �J ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft �J DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft r/ ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft l✓ 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 It DEPTH ft DISTANCE TO NEAREST WELL A ft FOUNDATION ft PROPERTY LINE ft C SEEPAGE PITS NUMBER WIDTH 'q-L11 -L11 ft DEPTH 1 S ft DISTANCE TO NEAREST WELL Igo ft FOUNDATION ft PROPERTY LINE S 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 COMPENS QN LAWS. MINIMUM HOUR ADVAN CE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE �tES�� _ DATE 11-(VI'� 1 O .D PARTME T SE O L � Application Accepted By Date Area , Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PAYMENT RECEIVE® PE Sc Received heck# Amount Permit/ Code INFO B ash emi d Date Service Request# Invoice# Permit ID# I ENVIRONMENTAL HEALIM T 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17