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ONSITE WASTEWATER TREAT INIENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 All OWNER NAMECJt1 AVIV \1C:;)�.j-"NI J� L' OWNER ADDRESS g7 w! CONTRACTOR D' A , PAiUUs-jr� CONTRACTOR ADDRESS "00 l V- mw-' l LJy' j LICENSE V C-42 ❑OC -36 OTHER A NUMBER FOR INSPECTIONS tXPIRES 1 YEAR FROM UATE ISSUE[ 1w CITY21P _ L_ N �L_, \ / / PARCEL SIZE FY/STATE/ZIP V (A L Hall 1V0 t) PHONE 4es G � 6 0-77 -� CITY/STATE/ZIP r R'j , ' 1XPIRATION DATE__ L�/ WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y_ ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: L7 NEW INSTALLATION )C REPAIR/ADDITION ENGINEER DESIGNEI 11 REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM �K DESTRUCTION I , INSTALLATION WILL SERVE: �\\❑ RESIDENCE ❑ COMMERCIAL X OTHER NUMBER OF LIVING UNITS: -P.1,- NUMBER OF BEDROOMS: -e— NUMBER OF EMPLOYEES: TERNATIVE SEPTIC TANK TYPE/MFG 1�-� - CAPACITY gal # OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit ID# DISTANCE TO NEAREST WELL it DISTANCE TO NEAREST: WELL J )ft FOUNDATION it PROPERTY LINE it ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS ReceivedCheck#/ By # OF LINES Date LENGTH OF LINES it Permit ID# DISTANCE TO NEAREST WELL it FOUNDATION 2 13 I Y it PROPERTY LINE it ❑ FILTER BED WIDTH it LENGTH /,�_ `J S ft DEPTH it DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE it ❑ MOUNDED WIDTH it LENGTH it DEPTH It DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it ❑ SUMPS WIDTH it LENGTH ft DEPTH it DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it ❑ DISPOSAL PONDS WIDTH it LENGTH it DEPTH it DISTANCE TO NEAREST WELL it FOUNDATION _ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH it DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it I HEREBY CERTIFY THAT 1 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 WORKER6 COMPENSATION L&WS. Application Accepted By \— Finai inspection By Nwjw-A " Character of Soil to Depth of 3 Ft:---- COMMENTS t:_COMMENTS P-Itfs l -r'L IS DATE ❑ cii'E^v1AL PERRN11T T___ Pit/Sump Soil Charaoter: / PE Code SC INFO ReceivedCheck#/ By Amount Remitted Date Permit/Invoice Service Request # # Permit ID# 2 13 I Y ;59Cc3Aa-j2- /,�_ `J S 2fs s4 42-01- J ` ( ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 Cr