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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 NUN-hiEFUNDABLE PERMIT (TALLZU`J 'JS:i-15.91 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI ` JOB ADDRESS (o L S Al • R/{M�t-117TC -EwD CITY/ZIP—T#0X VTVw q�� p % / 611 r - p /J� CROSS STREET y4/ N&,2 AD APN '� PARCEL SIZE � 1� OWNER NAME 10W 11*0 lb--010VIr. INFO PHONE s i Date OWNER ADDRESS Invoice # CITY/STATE/ZIP WELLI� CONTRACTOR GorJSfi u�F O/�( _ _ PHONE -One) p CONTRACTOR ADDRESS /'V BA C. ?G:y FILTER BED CITY/STATE/ZIP ft LENGTH ft LICENSE Ill' (:-42 ❑F 'C-36 OTHER NUMBERYu j 3G EXPIRATION DATE 0!? WELL WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATIO14: Coordinates X Y D PERC TEST # I 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: l RESIDENCE F1 COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LENGTH OF LINES /'On � ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft It PROPERTY LIN✓0 DEPTH O 7N ft ft PROPERTY LINE �pA ZZI� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAKI 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. SIGNED Application Accepted By Final Inspection By Character of Soil to D th of 3 COMMENTS .. I� -%I . n 0 wlve-k DATE O • EPARTMENT USE 007fNtLY ��Z'yv/ Date Area Employee ID# Date 19 ❑ BPt fAL ERMIT - Approved by Pit/Sump Soil Character: PE SC LEACH LINES LEACHING CHAMBERS % / 611 r # OF LINES Permit/ Code INFO B s Remitted Date Service Request # Invoice # DISTANCE TO NEAREST WELLI� t2 ft FOUNDATION ❑ FILTER BED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH It LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SEEPAGE PITS NUMBER_ WIDTH ft DISTANCE TO NEAREST WELL ft FOUNDATION LENGTH OF LINES /'On � ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft It PROPERTY LIN✓0 DEPTH O 7N ft ft PROPERTY LINE �pA ZZI� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAKI 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. SIGNED Application Accepted By Final Inspection By Character of Soil to D th of 3 COMMENTS .. I� -%I . n 0 wlve-k DATE O • EPARTMENT USE 007fNtLY ��Z'yv/ Date Area Employee ID# Date 19 ❑ BPt fAL ERMIT - Approved by Pit/Sump Soil Character: PE SC Received (iNhecRV Amount Permit/ Code INFO B s Remitted Date Service Request # Invoice # Permit ID# 2 Z 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 7