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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-KEFUNDABLE NERM17 GALL (ZUJ) J r i-/b'J/ FOR INSPECTIONS CXPIHES I T tAH FHUM UA I t ISSUtL JOB ADDRESS �/�LI/ut-t1 C i /� —0 C-44%% r%Twt-- _.�%tSJ - CITYIZIPi_I_VUr I�/M l 2 aIiwL'r CROSS STREET �3MM" 1__�LJ Q f/C�o ___ APN J-.1- J 010 ( (0 PARCEL SIZES + � l OWNER NAME iJ�n i\� VF�3. .L��f� .__ _ PHONE OWNER ADDRESS f �� SL _-_- __ _ _____ CITY/STATE/ZIP %�"rn T�3Ll (fes CONTRACTOR /�Ki-S — ,�' PHONE 44_ � �P CONTRACTOR ADDRESS A-) A cm _ _ _ CITY/STATE/ZIP __ 1 e-.+ I ✓� LICENSE ❑ JC -42 ❑ IC -36 OTHER NUMBER_ EXPIRATION DATE V o l WATER TABLE DEPTH: �' 7 _ ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/ADC Coordinates X Y LAND USE APPLICATION # TERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I1 COMMERCIA I OTHER NUMBER OF LIVING UNITS: + NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES: 01 SEPTIC TANK TYPE/MFG ✓ CAPACITY _ gal # OF COMPARTMENTS OIL ❑ GREASE TRAP TYPE/MFG _--__ CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION _ 1 _ _ It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP---,-- -- ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES U LEACHING CHAMBERS # OF LINES LENGTH OF LINESA&W ft DISTANCE TO NEAIjEST WELL `t FOUNDATION Amount Remitted ft PROPERTY LINE ft /FILTER BED WIDTH � ft LENGTH S ft DEPTH I ft _ DISTANCE TO NEAREST WELLS ft FOUNDATION � It PROPERTY LINE ft ❑ MOUNDED WIDTH - ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ___ _ It FOUNDA ZION _ ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH _ ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH .- ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOLINDATION _ ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER __ . WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDA NON _. - It 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, SIGNED Application Accepted By.' -t-' Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS AIQciit677- w D FOR INSPECTIONS - PLEASE CALL (20. TITLE CtPA �1 �h1`r _ DATE DEPARTMENT USE ONLY L- Date I I 1 12 Area `l ` Employee ID#4�vv-4'_� _ Date_ Z CI SPECIAL PERMIT - Approved by Pit/Sump Soil Character: _ PE Code SC INFO Received EW Cash Amount Remitted Date A:2->, I��o � IA006 Permit/ Invoice # Permit ID# Service Request # 5Iwo� - 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r.