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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTC'4 AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL ,209 953-7697r-OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED -JOB ADDRESS 117(o-5 CITY/ZIP A tf Y CROSS STREET A P N � � PARCEL SIZE Z v z OWNER NAMEle;-.l. ` PHONE v OWNER ADDRESS d/ _CITY/STATE/ZIP Off qY206 4SWIC4 4 �.i CONTRACTOR � 1�� 7f G',�.� PHON (/ 2✓ CONTRACTOR ADDRESS _CITY/STATE/ZIP W �J qLICENSE 1 I C-42 11 C-36 OTHER -f> NUMBER 1 S 7 EXPIRATION DATE3 0 //"L WATER TABLE DEPTH: EOGRAPHICAL INFORMATION: Coordinates X Y LPERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION R PAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE LJ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: `1 SEPTIC TANK TYPE/MFG r dy CAPACITY gal #OF COMPARTMENTS z ❑ GREASE TRAP TYPE/MFG c. CAPACITY gal gal #OF COMPARTMENTS'r_ DISTANCE TO NEAREST: WELL ft FOUNDATION ` � ft PROPERTY LINE2-151-tit ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS / #OF LINESn� LENGTH OF LINES Ofd- 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 ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE NOV3 (!DISPOSAL PONDS WIDTH ft LENGTH ft DEPTHft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERT file4f ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH EN N ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIH FNTAi 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 COMP NS �(ON LAWS. MINIMUM �SHOU ADV N ICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED A TITLE DATE c+ V O D ARTMENT LASE CYN Y Application Accepted 1 PE Date Area Employee ID# Final Inspection By � Date CI SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft:v Pit/Sump Soil Character: COMMENTS LA�� ID PE SC Received Chec Amount Permit/ Code INFO B ash emifte Date Service Request# Invoice# Permit ID# awl 8 it i 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17