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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-REFUNDA pB —L 7E `F/ERM11 7 JOB ADDRESS / ,J 1 GALL (209) 953-7597 FOR INSPECTIONS CITY/ZIP EXPIRES 1 YEAR FROM DATE ISSUEI 4.7,4L4 (-A 9 S 3 3 CROSS STREET W44; APN' ��y�� 7 � PARCEL SIZE c� OWNER NAME ? 131'P i✓ PHONELaj�� /D -Ru OWNER ADDRESS �rD , D vG ` CITY/STATE/ZIP 21 (�%G��`/ �)e,V 7-)�2- CONTRACTOR - I�-,�s�eCddL��A /� Y J7 L J��'L7! 1 /I/ PHONE CONTRACTOR ADDRESS �/T G %3 y ZLf / .CITY/STATE/ZIP CG -r / Y3 Uj LICENSE C-42 P C-36 OTHER NUMBER /1 EXPIRATION DATE 10-31 _ w V WATER TABLE DEPTH:` — 7-0 ft GEOGRAPHICAL INFORMATION PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION R PAIR/ADI Coordinates X Y 13-0 LAND USE APPLICATION # IN ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL I_i OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:.__ NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE _ TYPE OF PUMP ,L --CAPACITY /O gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Received B # OF LINES Amount Bernitted Date DISTANCE TO NEAREST WELL ft FOUNDATION FILTER BED WIDTH It LENGTH ft DISTANCE TO NEAREST WELL1 ft Y 2 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 ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION _ ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION LENGTH OF LINES M ft PROPERTY LINE ft DEPTH W � �Z ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE RAVft DEPTH RP� ft ft PROPERTY LINE - eb ft DEPTH APR I �� ft ft PROPERTY - mroldft VA DEPTH E Qulrr ft IT ft PROPERTY LI � L ; 1ZmgI.At ft 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. Ivllpr IVIYI c-► IVVn h✓ P71V IVV I MOT- nCUiWIn CU Vwn IIVJrC{.i IIV/vav - r-L.CMJC Lot -IL-1- 1,4uzl .7Jr�/U9 I/,` SIGNED TITLE 511.4' ('V i� 4 �- DATE � b l r Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS -JtE LISE QN4 Y Date • Area Employee ID# 00, Date 2 ❑ SPECIAL PERMIT - Approved by W[ Pit/Sump Soil Character: PE Code SC INFO Received B hec Cash Amount Bernitted Date Permit/ Service # Invoice # Permit ID# =Qq �Request 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17