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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN 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 � # OF LINES ) LENGTH OF LINES w ft DISTANCE TO NEAHEST WELLS CITY/ZIP &V" 22 ❑ FILTER BED WIDTH It LENGTH % DISTANCE TO NEAREST WELL APN O 3 :I U PARCEL SIZE f CROSS STREET ft DEPTH &j)ft DISTANCE TO NEAREST WELL - OWNER NAME 111K Z=rZO /,Q _ PHONE OWNER ADDRESS ` V ,- A C (I rV1 Q U _ CITY/STATE/ZIP CONTRACTOR 6P4 wz_ J % - 0/ei _. _ _ _— PHONE 36 9 z 7 CONTRACTOR ADDRESS 31b DlSohl /?,e– _ _CITY/STATE/ZIP _Z4 LICENSE FOLr,-42 ❑ IC -36 OTHER NUMBER V5,1910 Ys` EXPIRATION WATER TABLE DEPTH: Com- ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # FBUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION P4�_ REPAIR/ADE Coordinates X Y LAND USE APPLICATION #_ IN ENGINEER DESII REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: K RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL It FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP_ ❑ PKG TX PLANT TERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) �fJ� y� LEACH LINES ❑ LEACHING CHAMBERS � # OF LINES ) LENGTH OF LINES w ft DISTANCE TO NEAHEST WELLS ft FOUNDATION 495 ft PROPERTY LINE )06 YO_ ft ❑ FILTER BED WIDTH It LENGTH ft DEPTH _ �,ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH --- ft LENGTH ft DEPTH &j)ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINENnV B ft El SUMPS WIDTH ft LENGTH ft DEPTH IU►/ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY �INIEj�( AQy,�, �lN nA� ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH MALT-Hnv�N ANT ft _ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ENT ft �/ ISEEPAGE PITS NUMBER 3 WIDTH :3' ft DEPTH '�01S" I ft DISTANCE TO NEAREST WELL_1�Y'_ ft -FOUNDATION SOS _ft PROPERTYLINE�QU�d- 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. MINI UM 24 HOUR 4DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED _ TITLE 1 ' 2 _ DATE %/� 1,7 Application Accepted By Final Inspection By Character of Soil to Dep of 3 COMMENTS -DEPARTMENT USE ONLY 'I Date Area —I ! _� ��. Employee ID# Un Date ❑ SPECIAL PERMIT -Approved by Pit/Sump Soil Character: 0LA/ I_n, 17roIri0a PE Code Sc Received INFO Amount asli Remitted Date Permit/ Service Request # Invoice # Permit ID# yz1� i5 2?2 9 k3 1 42-01 5/5/17 / ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 6 T