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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 EXPIRES 1 YEAR FROM UATE ISSUED JOB ADDRESS �/ CITY21P ^se°G �,1 r/ 5-3 CROSS STREET /�"%C C � / % APNN / 7 -.2 ea- 0 � PARCEL SIZE 40,0 OWNER NAME !i `Ori •!f m/��/ t A e, S/)I, Q 1�I PHONE �✓ OWNER ADDRESS �`� 7 I��'� /2� � NOePTY/STATE/ZIP d .SC a/DI's CONTRACTOR / a / es wAJt-4e 4t, -.f/ PIS _ -PHONE aly'e-? 7 -2/ ©/ CONTRACTOR ADDRESS ®0 / �/ __CITY/STATE/ZIP lJ e A d ilr o L SG LICENSE IR" C-42 71 C-36 OTHER NUMBER 8736" _ EXPIRATION DATE jr '1/ �O WATER TABLE DEPTH: _ tt GEOGRAPHICAL INFORMATION: Coordinates X Y [I PERC TEST # LBUILDING PERMIT # _ LAND USE APPLICATION #_ TYPE OF WORK:, / NEW INSTALLATION REPAIR/ADDITION / ENGINEER DESIGNED /ALTERNATIVE 0 REPLACEME P T 7 A /h 1r, I OUT -OF -SERVICE SEPTIC SYSTEM W DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I.I COMMERCIAL �f C� OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: V SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG 0( h TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY �r! gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS It FOUNDATION ft PROPERTY LINE ft _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Received By_ _ # OF LINES ate DISTANCE TO NEAREST WELL Permit ID# it FOUNDATION ❑ FILTER BED WIDTH ft LENGTH 5P V67 DISTANCE TO NEAREST WELL ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL It FOUNDATION ❑ SUMPS WIDTH ft LENGTH DISTANCE To NEAREST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION ft ft ft ft LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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. MINIMUA1.24 H12UR.ADINCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-76974 SIGNED TITLE_ Owren ! r DATE DEP- Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS 01,tJ 744L h'C- 10 L rw�. U1 sit 41l wk -C 'mcry U�cvwL'r Date_ 1 Area Employee ID# ,QrinwT(i�- Date I 11 W 15" F:1 SPECIAL PERMIT -Approved by Pit/Sump Soil Character: h Glass 17ro x,t J", It -O k) 1 w {.•> ht C -� 1 o y PE Code SC INFO Received By_ Che ash Amount RemittedService ate Permit/ Request # Invoice # Permit ID# 233 5P V67 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17