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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT -P✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PER IT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE+ ISSUED JOB ADDRESS �_ _ - I ►/�J CITY/ZIP CROSS STREeT T Gi C� W' 1 _ - APN __ `� 'T V /9 / PARCEL SIZE OWNER NAME �i��►GSC � - __ 1 -1 JJJrI PHONE ZV�"'4/16� �/ ) OWNER ADDRESS 77,a-£1, ��' _ CITY/STATE/ZIP f_O" naln / CAT CONTRACTOR �""3& 1� 4)apn % �- _. _ PHONE CONTRACTOR ADDRESS q sz_tz �� _ - - CITY/STATE/ZIP it 0r) \ X: )- iii LICENSE £-42 7T OTHER NUMBER � z.zk _ _ EXPIRATION DATE WATER TABLE DEPTH: ft 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 INSTALLATION WILL SERVE: r -i- RESIDENCE I I COMMERCIAL [I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ t NUMBER OF EMPLOYEES: ;a SEPTICTANK TYPE/MFG CZ1X_C`_ CAPACITY ` Z�OgaI # OF COMPARTMENTS 2— ❑ GREASE TRAP TYPE/MFG _ _ CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL _ ft FOUNDATION _ ft PROPERTY LINE h ft ❑ LIFT STATION SIZE TYPE OF PUMP------- _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES 4601 ft DISTANCE TO NEAREST WELL �� ft FOUNDATION D _ ft PROPERTY LINE it F] FII TFR RFn WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST ❑ MOUNDED WIDTH DISTANCE TO NEAREST ❑ SUMPS WIDTH DISTANCE TO NEAREST ❑ DISPOSAL PONDS WIDTH DISTANCE TO NEAREST WELL _____. tt FOUNDATION ft LENGTH WELL _ ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft ft ft DEPTH ft PROPERTY LINE DEPTH WELL _.__ _ It FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER _ ___ WIDTH-------- ____-___ __ _ft DFPTH DISTANCE TO NEAREST WELL--- ft FOUNDATION - ft PROPERTY LINE 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. SIGNED _ TITLE DATE �� *\� DEPARTMENT USE QNLY Application Accepted Ry DateY4 Area _1Employee ID# Final Inspection By Date -/01—/ igl/ I _ ❑ SPECIAL PERMIT - Annroved by Character of Soil to Depth of 3 Ft: C- 7 _ Pit/SUmp Soil Character: COMMENTS _;RDQM C-fb W-1 T- nkC- _6✓N / AlVe-M Il PE SC INFO Received heck# Cash Amount Remitted Date Permit/Code Service Request # Invoice # Permit ID# 'C'v 1 b 1'1 SiZZ515 %$� (o IF 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r