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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P /S SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS A ,€XEIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS jSffS ] V- F44 Y Ljn __ CITY/ZIP ( Cd, 15 .5 CROSS STREET �77/C tone/ _ APN __ - r 5.2 PARCEL SIZE �2 , 7 OWNER NAME I i6:L11_tw -^. _(` PHONE cT� OWNER ADDRESS _�/ T0' -d► ____ - - CITY/STATE/ZIP 1 CONTRACTOR /� _ �' � 1 1 I`C^G � - / ] ��((� rtP' ____._..___ _ PHONEne- �'✓ CONTRACTOR ADDRESS (�_ �A L= �_ _ ___--_ _ _ _CITY/STATE/ZIP _ Yh f ►1 LL e4. ` =2 J : LICENSE ❑' C-42 ❑' IC -36 OTHER A NUMBER EXPIRATION DATE am % Yi WATER TABLE DEPTH: - ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # _____ _ LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDIIION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: �ESIDENCE [ I COMMERCIAL 1 1 OTHER i1 , NUMBER OF LIVING UNITS: 9 NUMBER OF BEDROOMS: ___ NUMBER OF EMPLOYEES: ASEPTIC TANK TYPE/MFG _P'T� CAPACITY ��_ _ -__ gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY _ gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL _. ft FOUNDATION_' j ft PROPERTY LINE �'jY ft ❑ LIFT STATION SIZE TYPE OF PUMP_ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft r FOUNDATION FILTER BED WIDTH �_ ft LENGTH ft it PROPERTY Y LINE ft DEPTH � ft _ DISTANCE TO NEAREST WELL1 _ _ _ ft FOUNDATION LiS 1 ft PROPERTY LINE Y�6 ft ❑ MOUNDED WIDTH ft LENGTH —_ ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH _.ft LENGTH _ _ it DFPTH PAY _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ECE[` r -n ft Lj _ ❑ DISPOSAL PONDS WIDTH - ft LENGTH _- ft DEPTH / ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE r� ft __- ElSEEPAGE PITS NUMBER WIDTH ft DEPTH E UogQUCy ft DISTANCE TO NEAREST WELL _ _ ft FOUNUAHON ft PROPERTY LIN '� DEA4R _R� 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 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED - TITLE_�s'1/1�_�_1 6-46 C DATE A J% Application Accepted B Final Inspection By Character of Soil to Depth of 3 COMMENTS `1 C^ . I . —. A i _ Date__ yr: Area _�_� Ci Employee ID# Date, llg</_�/' _ CJ SPECIAL ERMIT - Approved by -;� uGr.•^ - Pit/. ump Soil Character: --- PE SC INFO Received Chec B ash Remitted Amount Date Permit/Code Service Re uest # Invoice # Permit ID# 42-01 5/5/17 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT r� m v v cn