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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 'AN JVAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 MnN-RFFt1NDARLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS j3400 m I C>PL E (�U CROSS STREETS L APN 2 OWNER NAME IN A&JJC;t7-- <*MA C t� -rP/AI CITY/ZIP —T�Z—Pty Lf DOZ f PARCEL SIZE I(& t� � PHONE V OWNER ADDRESS----CITY/STATE/ZIPV`� CONTRACTOR v J ` ��S? B-'�t�� N ` f _ - - - _ PHONE 2-©� CONTRACTOR ADDRESS (� 1Z N' INV r CITY/STATE/ZIP L`> p -x- CA !?1!5 LICENSE ❑: C-42 ❑ C-36 OTHER A- 1 Z NUMBER 1151 EXPIRATION DATE zt,, (� 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: I-1 RESIDENCE If COMMERCIAL [I OTHER L I NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:- __ NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY 44#!aWXal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG - _ CAPACITY gal # OF COMPARTMENTS 7� �_ �� DISTANCE TO NEAREST: WELL j It FOUNDATION ft PROPERTY LINE ft LIFT STATION SIZE 0,00 TYPE OF Pq,UpMPJ)Ad+LW- ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) if/ ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH _ ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft MOUNDED WIDTH 5,0 ft LENGTH __.. _ 130 ft DEPTH r ft DISTANCE TO NEAREST WELL 10 0 ft FOUNDATION ft PROPERTY LINE S� ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH _ ft DEPTH ft 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. MINIMUM 24 HOU DVAN E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED _ ' TITLE__ —��DATE Application Accepted dike Datef Area s e/ I t Employee ID# Jt �VYLF-V Final Inspection By DateAw 11SPECIAL PERMIT - Approved by Character of Soil to epth of 3 Ft: mp oil Character: COMMENTS ✓h 2 x k t►ff�Sp�C. �. % _L3i:::e_:i�' —� 1100_ o o �B _ 16 - vli ip � S eDf � il a T► � �I� ,�1�K. � � J2Cc' �' �i Y' PE Code SC INFO Receive B heck#/ ash -Amount Remitted Permit/ Date Service Re quest # Invoice # Permit ID# 4P-01 ONSITE WASTEWATEH TRTMNT SYSTEM PERMIT 5/5/17