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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT r GALL (zU9)9b3-769/FOR INSPECTIONS LXPIRES 1 YEAR FROM UATE ISSUE[ 1 JOB ADDRESS 8 J -3Q �et46 d- �_� CITY/ZIP /�L1wc4l/» CROSS STREET /V &a.14: 1IL r►CLI( APN © /cl PARCEL SIZE + Q + OWNERNAME ArImrl (o fAi,CfC•' _ PHONE- 20Y- 00—(,621 OWNER ADDRESS & 13a 2 7 __ _ _ . - -_ CITY/STATE/ZIP cle uie.d 1S`2.2 7 CONTRACTOR _ PHONE CONTRACTOR ADDRESS —CITY/STATE/ZIP LICENSE ❑ 'C-42 ❑nC-36 OTHER NUMBER _ __ _EXPIRATION DATE___. _ WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y IJ PERC TEST # I BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/Ac)DITIOR ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: ?4r, RESIDENCE I-] COMMERCIAL 40*11Eft NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: Z NUMBER OF EMPLOYEES: ?I-,- SEPTIC TANK TYPE/MFG C� CAPACITY �2E� _ gal # OF COMPARTMENTS rZ- ❑ GREASE TRAP TYPE/MFG CAPACITY - _ _ _ gal # OF COMPARTMENTS INFO DISTANCE To NEAREST: WELL t>10 _ ft FOUNDATION 7 ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) VK LEACH LINES '-4EACHING CHAMBERS l� ' Y Ila- # OF LINES _ am LENGTH OF LINES 6�5— ft DISTANCE TO NEAREST WELL—/ ft FOUNDATION to ft PROPERTY LINE 57 ft ❑ FILTER BED WIDTH ft LENGTH _ Invoice # ft DEPTH It INFO DISTANCE TO NEAREST WELL Service Request # ft FOUNDATION 2t j ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft PET— DISTANCE TO NEAREST WELL — ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS 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 FOUNDATIONrft PROPERTY LINE ft l SEEPAGE PITS NUMBER 2 WIDTH A ft DEPTH L5,— It DISTANCE TO NEAREST WELL ft FOUNDATION ! !� ft PROPERTY LINE 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. MINIMU 24 HOUR-ADVANCEtIOTICE REQUIRED FOR INSPECTIONS - PLEASE_ CALL 209 953-7697 SIGNED __ TITLE O_ "- ef- _. DATE i"9 01 5 �-D o- $ G- J a h an t R.P. 0. � 2GG.17 1 hi -AL DE.PARTMENT USE �L Y Application Accepted By Date Area Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Dept of 3 Ft: Pit/Sump Soil Character: _ COMMENTS A, Cg-w �_r6e.,-a. coOnN194 (�-,r PE SC Received Check#/ Amount Date Permit/Code Invoice # Permit ID# INFO 8 Cash Remitted Service Request # 2t j iS�c. PET— -0 0 0 30 — 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17