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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMITCALL, 209 9q-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED hJOB ADDRESS 5 ) r CITY/ZIP C CROSS STREET APN 7�l� .5 TPARCEL SIZE a - I OWNER NAME /'trY1 G1/y—�1 l (� iWl�i� w PHONE4 OrwiLA- -rk' OWNER ADDRESS O _ Cv\ / CITY/STATE/ZIPlE � /te r /�/ ��-7 �,c.`/ � CONTRACTOR /� { ,7�� PHONE,) (i ��F�&(-ok J / /� L _ �L CONTRACTOR ADDRESS AZ S-L!!� ;/✓_&l-" CITY/STATE/ZIP 7�tk�f— LICENSE 11❑C-42 &l^ -G36 OTHER NUMBER ! OEXPIRATION DATE /® r / / J —o WATER TABLE DEPTH: L I PERC TEST # TYPE OF WORK: t ` a / U ft GEOGRAPHICAL INFORMATION: BUILDING PERMIT # NEW INSTALLATION REPAIR/ADC Coordinates X Y LAND USE APPLICATION #_ IN ENGINEER DESII REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION ' INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: - SEPTIC TANK TYPE/MFG GREASE TRAP TYPE/MFG /AL CAPACITYSO V gal # OF COMPARTMENTSy CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL _!�70 "f ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Received BM Check#/ pash # OF LINES Date LENGTH OF LINES Invoice # Permit ID# DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH n li DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH �VI._ DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LIN TII FAIT ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH Mew DISTANCE TO NEAREST WELL ft FOUNDATION 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. IV111YUVIvrv1 IYV 11(iC ncwvrncl✓ rvn 11Y17rCli I IV/YJ - rLGF1JC L t-tL-1- jzu. SIGNED TITLE_ clf/1 JYNA--1 DATE Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS 11 M ft ft ft ft ft ft ft ft ft ft ft EPARTMENT USE,0NLY Date Area Employee ID#� Date LF ❑ SPECIAL PERMIT -Approved by Pit/mp Soil Character: i�t��A-rrr� PE Code SC INFO Received BM Check#/ pash Amount Re 't d Date Permit/ Service Request # Invoice # Permit ID# c7 A5 S Q.66 �� 7/ f� j�ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/1 5/5/17 ! (J