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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUN-REFUNDABLE PERMIT <br />(TALL (ZUy) Yba-115YI FOF? INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS ' /A�► CS -fit in Kn CITY/ZIP K j b fN C � _ _ <br />Aa <br />CROSS STREET l� APN 2 S �2Q b �- PARCEL SIZE <br />^ _ <br />OWNER NAME �r1 Pcxe I Y F. r.'n j PHONE G] <br />OWNER ADDRESS 13101 LJ LA'lAt fown 1�0 CITY/STATE/ZIP A4 <br />ecji 1 e— ` b l <br />CONTRACTOR M 1140 S � + � N �i-- �/ PHONE J-Lj (e -- <br />CONTRACTOR ADDRESS P—j 6,-3K & Jam' I�s� CITY/STATE/ZIP <br />LICENSE I I C-42 C-36 OTHER A NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: til ) ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />, PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: f._ ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />W01SEPTIC TANK <br />TYPE/MFG _ A tZ <br />_ CAPACITY rIS <br />gal <br />OMPARTMENTS❑ <br /># OF COMPARTMENTS-2— <br />LlGREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />WELL <br />DISTANCE TO NEAREST: WELL x <br />ft FOUNDATION I <br />ft <br />PROPERTY LINE d -b t It <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES C6 I ft <br />a <br />DISTANCE TO NEAREST WELL I ft FOUNDATION 10 ft PROPERTY LINE 3.-5 It <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />Amount <br />Remitted <br />Date <br />ft <br />DEPTH ft <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />`i 1 I <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />IF PIT <br />ft PROPERTY LI ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH I:CE.IV -- ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LIQ ft <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH 7 ZpW It <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />eedd..II <br />ft PROPERT44]IN ^-. ft <br />El SEEPAGE PITS <br />NUMBER <br />WIDTH <br />Ely�jROPIT!.A It <br />ft DEPTH y N � T.. <br />DEPARTAi/Jrlu, <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />vn 11v17rca,. r rvrvo - r-1-cnoc rcv <br />TITLE i DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By Date -1 - <br />Final Inspection By'� Date l <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil <br />COMMENTS <br />Area III CI ti Employee ID# A h✓n/'(� <br />❑ SPECIAL PERMIT - Approved by <br />Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />hec <br />sh <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />gxl1 <br />is <br />SS <br />`i 1 I <br />=}qUk <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />