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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT f SAN JOAQUIN BOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT �CALL 20/9 953-76x97 FOR INSPECTIONS n EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ��J/��YV -e'- li i//�1� �V7L� L�+: -- 1` CITY/ZIP CROSS STREET /l K p APN D� —70o-1 � PARCEL SIZE 0, OWNER NAME �/I(i% vy/ C{Y�� `-, Ir✓1 -�q_ _ PHONE 6!Q� ) %�}'i/ O� OWNER ADDRESS ZiLV lIZ&'61raz/Cie`^/7r�-Iz CITY/STATE/ZIP qS 20 77 CONTRACTOR — PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE L_I C-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: CO dinates X PERC TEST # 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 L I COMMERCIAL [I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: ., SEPTIC TANK TYPE/MFG CAPACITY ZWO gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL w1/% ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT O SAND OIL SEPARATOR (ENCLOSED SYSTEM) PE Code ` to Received B LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES _ _ ft DISTANCE TO NEAREST WELLNCWV-(--ft FOUNDATION �' ft PROPERTY LINE �' It ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft LIt ❑ MOUNDE ' H ft LENGTH ft DEPTH ft D1"A d ; . EAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMP WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE+ ft - SEEPAGE PITS NUMBER V WIDTH 'TZ1I ft DEPTH /mss ft DISTANCE TO NEAREST WELL&Q ft r FOUNDATION _ft PROPERTY LINE 4- 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 COMPENSAIION LAWS. MINIMUM -24-HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95/3-7697 SIGNED -_ TITLE d %/V IZ DATE q / 3 t 19 00 SA J its Pu' 9F1�I ,, TL 1EPARTME0jTQSqON-LY Application Accepted By Date Area (Employee ID# r� l� Final Inspection By Date 1 SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE Code SC INFO Received B Cas Amount Remitted D to PermiU Service Request # e rmit ID# D 5 ldS Ob- i- �- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17