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�s ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUItPCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 a NON-REFUNDABLE PERMIT GALL2U9 95 7F NR INSPECTIONS 1 YEAR FROM UATE ISSUEI JOB ADDRESS �^' 1 r N N-kJ �� /3-1169 {LXPIRES CIL 3 �� CITY/ZIP LSO i C -A C CROSS STREET 1��G� �t`I APN D 14 q 116 2. y PARCEL SIZE OWNER NAME �t N z� �C M i�' p L (�a�ri ell e r -I uS PHONE 1� OWNER ADDRESS S A h � /C�vrJS� f, V�, CITY/STATE/ZIP CONTRACTOR \'Ar -1 t CoAS7 CSAILKIJ 1111L I I � ` - _ _ PHONE zoo r -7 -5&)4 CONTRACTOR ADDRESS S1 NIklfV e%) 57 CITY/STATE21P I -b -o AS L90 LICENSE ❑ C-42 ❑ 'C-36 OTHER A NUMBER SS h67 EXPIRATION DATE 2010 _ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # - LAND USE APPLICATION # TYPE OF WORK: 71 NEW INSTALLATION E AI DDI i ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I i DESTRUCTION Application Accepted �By''' ' Final Inspection By /y'�:: Character of Soil to Depth of 3 COMMENTS '1, 1 DEPARTMENT USE ONLY ,'11 Date ))-)I-/ ;� ___ Area � _ Employee ID# Date 0711Zd18 .___ I 1 SPECIAL PERMIT - Approved by X SflmQ_Sw-&c Pit/Sump Soil Characte : AQQ 0 j,, /J� A�N/►1A�1 _ t ISI l it ,S u-w�.11 �1 (G W PE Sc Received Code INFO a aI 3 II �' — Dat i 1� _�SR,667k4KI ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit ID# i S DISTANCE TO NEAREST: WELL CIO ft FOUNDATION _ It PROPERTY LINE ft ❑ LIFT STATION SIZE _ TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS ►J�t Ami # OF LINES LENGTH OF LINES 4z. , ft DISTANCE TO NEAREST WELL L �\ ft � c FOUNDATION ft PROPERTY LINE J ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN kkA. ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH _ ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft `SANJOA,, ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft - _. DISTANCE TO NEAREST WELL ft � FOUNDATION ft PROPERTY cNV O OU ft SEEPAGE PITS NUMBER WIDTH_ ft DEPTH 2S DEpART Ar � ft _ DISTANCE TO NEAR EST WELL ISO` 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS/PLEASE CALL (209) 953-7697 SIGNED _ TITLE .� ��'� / _ _ DATE L ( 7 Application Accepted �By''' ' Final Inspection By /y'�:: Character of Soil to Depth of 3 COMMENTS '1, 1 DEPARTMENT USE ONLY ,'11 Date ))-)I-/ ;� ___ Area � _ Employee ID# Date 0711Zd18 .___ I 1 SPECIAL PERMIT - Approved by X SflmQ_Sw-&c Pit/Sump Soil Characte : AQQ 0 j,, /J� A�N/►1A�1 _ t ISI l it ,S u-w�.11 �1 (G W PE Sc Received Code INFO a aI 3 II �' Chec Amount Remitted �� SS Dat i 1� _�SR,667k4KI Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17