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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVFNUE - STOCKTON CA 95205 - (209) 468-3420 1'ON-REFUNDABLE PERMIT C;ALL1{ Uyl yb3-/UJ/ FOR INSPECTIONS tX/PIRES l YEAR FROM DATE 155Ut1 JOB ADDRESS ./a0 / I - -----.CITY/ZIP �otj CROSS STREET Fp-e /n on APN _�13 - ,;2 7O 3`/ ------PARCEL SIZE-3,q ,q OWNERNAME^S I I _f DG d (0c,✓ 5 PHONE C'90 -c/ OWNER ADDRESS -7 G.MC LC _s LO✓e- CITY/STATE/ZIP-561n-e its e'(V i1a= CONTRACTOR TE ('L'f 3Tizk.tC77:0'V PHONE 9( ? q-2 1 TT - CONTRACTOR S /' CONTRACTOR ADDRESS PO. UO>< -(b �1__ ____CITY/STATE/ZIP Ell< ("Zooc LICENSE E1/42 F1 C-36 OTHER _ NUMBER ZZ� ILe EXPIRATION DATE 9 /3Q / ^7 m ,o y F WATER TABLE DEPTH: �O ft GEOGRAPHICAL INFORMATION ❑ PERC TEST # BUILDING PERMIT # I_ X LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION Y INSTALLATION WILL SERVE: IJ RESIDENCE i/ COMMERCIAL I. 1 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ _ - _ _ NUMBER OF EMPLOYEES: TERNATIVE ® SEPTIC TANK TYPE/MFG L LvellCtiE-T-t= _TF-- CAPACITY `,�� gal # OF COMPARTMENTS 2- ❑ GREASE TRAP TYPE/MFG CAPACITY _ L3 gal # OF COMPARTMENTS Amount Remitted IV DISTANCE TO NEAREST: WELL ft FOUNDATION _ It PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) I LEACH LINES Y LEACHING CHAMBERS # OF LINES LENGTH OF LINES ` _ ft It DISTANCE TO NEAREST WELLj&1A77! _ ft FOUNDATION ft PROPERTY LINE % ❑ FILTER BED WIDTH _._ It LENGTH .__ — It DFPTH It DISTANCE TO NEAREST WELL ft FOUNDATION _ It PROPERTY LINE ft ❑ MOUNDED WIDTH _ ft LENGTH _ -_ It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION CV? WIDTH r It LENGTH It ft PROPERTY LINE It DEPTH ft SUMPS _ _ _ f 0 DISTANCE TO NEAREST WELL ft FOUNDATION _ It PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH _ ft LEN H _ ft DEPTH ft DISTANCE NEAREST WELLFOUNDATION 3 _ ft PROPERTY�LINE, ft IDTH :To ft DISTANCEOT—�1�7Ett n9 Hi Bid-'6��ff PR(1PFRTY—= 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIM 24 H *R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE_—Qc,y�1>EZ'� _ DATE P' Application Accepted Final Inspection By ' Character of Soil to COMMENTS SO Y Area C�q Employee ID#� SPECIAL PFIFE - Approved by FdE it C aracter: _______ n ANI, f1�i[�il\�Z�t'�.i�►.i'h Ii�rrlr_i'il��vL�r -r1 _, '�'"' �3�'�11r s�tiL�t��-1i�J_ft• PE Code SC INFO Received B Check Amount Remitted IV Permit/ate Invoice # Permit ID# Service Re uest # � --- -- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17