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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 ��CJ 6 CITYRZIP ) i' CROSS STREET / APN �QO , vv f PARCEL SIZE _ v 421:4 OWNER NAME ' Y! PHONE 7 � -/.��/✓ U n OWNER ADDRESS ef / CITY/STATE/ZIP CONTRACTOR G J/` / PHONE ;-S J __ CONTRACTOR ADDRESS � � L Y _ec-z G- f- CITY/STATE/ZIP � C f(y LICENSE C-42 1 �C-36 OTHER � NUMBER -? EXPIRATIONDATE j z —meg WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATIO : Coordinates X Y 44 .1r PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE D COMMERCIAL ❑ OTHER J NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: n NUMBER OF EMPLOYEES: $h SEPTIC TANK TYPE/MFG CAPACITY 2- gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS In DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE //� r ft ❑ LIFT STATION SIZE TYPE OF PUMK ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) -/ ✓fir 1 $ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft \ DISTANCE TO NEAREST WELL It FOUNDATION��.ft PROPERTY LINE s� ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE Irm, ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH A ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINENn � �A ft L3 SUMPS WIDTH ft LENGTH ft DEPTH NnI/ n n ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY I ' LU/R ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ENInAQUIN�•._ ft DISTANCE TO NEAREST WELL ft/FOUNDATION ft PROPERTY N'rA ft 13SEEPAGE PITS NUMBER WIDTH iC f) ft DEPTH lr i' t/TMENt ft DISTANCE To NEAREST WELL ft FOUNDATION j9 ft PROPERTY LINE T 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. 48 MINI 14 20 HOUR 4WAN NOTIC REQUIRED FOR INSPECTIO S-PLEASE CALL 209 953-7697 l Q SIGNED �� TITLE DATE L,/— �G lot i DEPARTMENT USE ONLY Application Accepted By Date 11 Areapf— Employee ID# Final Inspection By Date I ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PiVS,,um Soil C�racter: COMMENTS AktA��k �C k Ole m QS�,r1 _ . i�1 f�c PE Sc Received a Amount Date Permit/ Invoice# Permit ID# Code INFO B Remitted Service Request# 0 30 t RoO� 2 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17