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ONSITE WASTEWATER TRLATMENT SYSTEM PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT,,t4 CALL 209 9_53-7697 FOR INSPECTIONS j tXPIRES TEAR FHL)M UAIt I55UtL JOB ADDRESS / 500 q4SSCx� - ____ _ CITY/ZIP ��aX �w iz APN 1 CROSS STREET /n/f�es �9/ '- %�{('6^,_ - - n - _ 0?/4��D� ` �� `''�' .P�ApR�CEL SIZE OWNER NAME N/ r Ple0 -9 l:X a&4z � �.(!�Jr�._rJ! 1 r --PHONE ff'y"/ 36-7— 4,35L /5 DOt� G! /1-1a1 (L►�erb�� A Dr LOtgfZ CA q S2 -VL__ OWNER ADDRESS /,�_ _______CITY/STATE/ZIP CONTRACTOR 44 c1 ` ��y�,�� ('` ^' PHONE za � I ��f CONTRACTOR ADDRESS 33 / "Ax �/iC -+ / CITY/STATE/ZIP 40V'� CA- ` �Z_4/- 0 LICENSE IT C-42 ❑L 1C-36 OTHER_ 2' NUMBER EXPIRATION DATE._ 0� WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION T' SEPTIC TANK TYPE/MFG •P �� CAPACITY 7-C -.30 gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL it FOUNDATION ft PROPERTY LINE it LIFT STATION SIZE _ TYPE OF PUMP (�%. O PKG TX PLANT U SAND OIL SEPARATOR (ENCLOSED SYSTEM) Code INFO B—'ersh ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES it DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it _ FILTER BED WIDTH it LENGTY Z� it DEPTH ';W i _� it DISTANCE TO NEAREST WELL L n� _ -_ it FOUNDATION O ft PROPERTY LINE S it ❑ MOUNDED WIDTH it LENGTH it DEPTH it DISTANCE TO NEAREST WELL ft p� FOUNDATION ft PROPERTY LINE PAYM1=bT_ it ❑ SUMPS WIDTH it LENGTH ft DEPTH RECEIVED it DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH OCT 16209— it DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LIME ft SAIJ JOAQUII COUNTY it ❑ SEEPAGE PITS NI IMAFR _ _ WIDTH it DEPTH — V ROWENTAL DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY H ALTH r)PPARTe��Tfrur it 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 ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION WS. MIA/IAAIIM 9A mnt AnvA F NnTICF REBf MF_n FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED Application Accepted Final Inspection By J Character of Soil to 6 COMMENTS w��ro b.se rv_E DATE Vu / I EPARTMENT U E ONt Y Date _._ Area Employee ID# Data / _ 1-1 SPECIAL PERMIT - Approved by of 3 Ft: Pitisump Soil Character: C_ 1 fati � �o �� Y /_ on 9 ZoL7 PE SC Received rCheckW Amount Dae Permit/ Invoice # Permit ID# Code INFO B—'ersh Remitted Service Request # 1713 = - 4-7T _--- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17