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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 CALL (209) 953-7697 FOR INSPECTIONS t_XPIRES 1 YEAR FROM UATE ISSUE JOB ADDRESS L �6'-G-3 SC INFO '---& &V Aj CITY/ZIP Fly 1474 Inggf� L,i__�5 jUt_ ;, CROSS STREET (� �� I) _ APN / PARCEL SIZE LI ' OWNER NAME _)tA U r) �! Luc`/ LU t _C__ PHONE % PA��r177 OWNER ADDRESS 1 v w� J' 3 _ _____CITY/STATE/ZIP _ v • I S I CONTRACTOR 1 / 1 f_Il�ts �� � AG ___ __- PHONE j"'t ��'�^XLr 6' CONTRACTOR ADDRESS - e, 6SA CITY/STATE/ZIP 1/ =4j&o L / 4!16 LICENSE ❑ C-42 ❑ C-36 OTHER st 1�3/ NUMBER EXPIRATION DATE /► \C WATER TABLE DEPTH: ^� ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT # P A -03- S7 LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPLACEMENT I_I HEPAIR/ADDITION OUT -OF -SERVICE SEPTIC SYSTEM Y I ENGINEER DESIGNED I DESTRUCTION INSTALLATION WILL SERVE: VAESIDENCE L) COMMERCIAL, ❑ OTHER NUMBI ER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: TERNATIVE n1"EPTIC TANK TYPE/MFG ��'-L CAPACITY iman gal # OF COMPARTMENTS_ " ❑ GREASE TRAP TYPE/MFG CAPACITY _ gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION I ft PROPERTY LINE 7:57 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) EACH LINES ❑ LEACHING CHAMBERS DISTANCE TO NEAREST ❑ FILTER BED WIDTH DISTANCE TO NEAREST WELL�y_ ft ft LENGTH # OF LINES 01.1 FOUNDATION I n ft ft FOUNDATION LENGTH OF LINES A ft ft PROPERTY LINE �� i ft DEPTH ft ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it I SUMPS �� WIDTH DZ _ ft LENGTH m. f ft DEPTH ft DISTANCE TO NEAREST WELL IZ y -u` ft FOUNDATION lot ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH IVFn ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE - ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH �yI Ott ft DISTANCE TO NEAREST WELL -__ ft FOUNDATION - _ft PROPERTY &MJ _ i,, GQ[71C� ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACI Ah�CEF�A(�T JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICE N CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. SIGNED 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PL TITLE /l"M�G�'-6 DATE I 1 '� DEPARTMENT USE ONLY Q Application Accepted By _ Date z' 1 Area Employee ID# r ' h ►�'iQ Final Inspection By�/Vk /�tili✓t ft's _ Date % ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft:�s�,e� ____ __� PiUSump Soil Character: __ COMMENTS PE Code SC INFO Received hec Amount sh Remitted Date Permit/ Service Request # Invoice # Permit ID# 63o 1170-► '9600-M-917 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17