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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 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS iq4L CITY/ZIP 5 r04 L .1 C G CROSS STREET C j PO> �C d APN ��000" v v PARCEL SIZE /'_ / d OWNER NAME 6ry 4000 �C-C PHONE � I qQ 4.3 23 13 OWNER ADDRESS o. � � 4 �- CITY/STATE/ZIP ��e� 1 n !/11 CONTRACTOR PHONE Z 1 :z k:>-3 3q }� CONTRACTOR ADDRESS / I 1y'�. PjS i�I� 1 CITY/STATE/ZIP �TU�TPCA- /5�` LICENSE I_I C-42 I C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIG ED/ALTERNAT E REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDE CE I I COMMERCIAL OTHER NUMBER OF LIVING UNITS: �f G� NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG if i[J CAPACITY L/ 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) ❑ LEACH LINES i I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION 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 �nrMft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 1A WCU ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI iO ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH lip,I �RON q COUNT. ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE " rAA-. � 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. INIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED - TITLE � DATE I L —1 J ." . DEPARTMENT USE ONLY � Application Accepte7epth Date / Area 'l Employee ID#� Final Inspection By Date 6 ' I SPE IAL PERMIT-Approved by Character of Soil to of 3 Ft: it/Sump Soil Character: COMMENTS PE SC Received h Amount Permit/Code INFO B 07�-- Remitted Date Service Request# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17