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r ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 14ON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS + 1�1 CITY/ZIP C4- f✓�/1r CROSS STREET APN a�j 0- v 70 K PARCEL SIZE v v v OWNER NAME PHONE ' OWNER ADDRESS C—fCITY/STATE/ZIP CONTRACTOR M i y� PHONE `7�s-lV/—I'9-css CONTRACTOR ADDRESS �n 6 r 'c L'[ o G CITY/STATE/ZIP Lr ��I��'�� 14C;4- LICENSE G'g-LICENSE C-42 I I C-36 OTHER NUMBER �dOS EXPIRATION DATE WATER TABLE DEPTH:41 i /V ft S�GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# " LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I R PAIR/ADDITION I i ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: �SIDENCE I I COMMERCIAL OTHER NUMBER OF LIVING UNITS: L NUMBER OF BEDROOMS: a NUMBER OF EMPLOYEES: o0,-"SEPTIC TANK TYPE/MFG Tn ITL CAPACITY �V I,C� gal #OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY +J gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL 7� ft FOUNDATION J�t ft PROPERTY LINE �c,54- 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 �L� ft DISTANCE TO NEAREST WELL I arJ' ft FOUNDATION qC) 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 It FOUNDATION ft PROPERTY CS e. ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH l� I Nft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH u ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPE u ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN A C4Q �IIIITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRE NSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 H UR DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE DATE y T i Q PARTMENT SE ONLY Application Accepted By Date 7 Area Employee ID# '►J �C�LaQ/ Final Inspection By Date �17L ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Plt/Sump Soil Character: C MMENTS PE Sc Received Amount Permit/ Code INFO B Fern ed Date Service Request# Invoice# Permit ID# L1'3 01 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17