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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 14UN-KEFUNDABLE PERMIT GALL (209) 953-7697 FOR INSPECTIONS l ` ` ExPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS 1-703!;-IM.5� -cub+s+ P-0 rr CITY/ZIP��%i �G�s:��% � �./�- CROSS STREET APN ��i J - 000 PARCEL SIZE • O OWNER NAME �f (i�iC/ PHONE OWNER ADDRESS a0 I ji . CITY/STATE/ZIP CONTRACTOR . �5 4-f<`•1 a -e i • PHONE CONTRACTOR ADDRESS k /.�'3c'�k �L�� i7 CITY/STATE/ZIP 444%i%J^�/l g LICENSE I ! C-42 I I C-36 OTHER _ P47 -NUMBER EXPIRATION DATE I C:� WATER TABLE DEPTH. ` , ft GEOGRAPHICAL INFORMATION: Coordinates X Y L! PERC TEST # 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: RESIDENCE 1 COMMERC L Z / _] OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:y NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) EACH LINES LEACHING CHAMBERS X11 # OF LINES LENGTH OF LINES 1146 ft Chec DISTANCE TO NEAREST WELL ,2 ft FOUNDATION 1�J ^ ft PROPERTY LINE 5 6 ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE lea, ft L] MOUNDED WIDTH ft LENGTH ft DEPTH INFO DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE `i ❑ SUMPS WIDTH ft LENGTH ft DEPTH / _ ft d,2104W2:� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH /J-ZAhCi,. ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ,nD FNT SEEPAGE PITS NUMBER -1 WIDTH �L, ft DEPTH + MENT ft DISTANCE ToZREST WELLI 6�tE ft �P�FS FOUNDATION �A� ft PROPERTY LINE 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. MINIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED 14 TITLE ✓] GCi�L`i� _ DATE 4 .A4 1 Application Accepted Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS TMENT S OhLY Date Area Employee ID# &4KIO Date ❑ SPECIAL RMIT - Approved by PiUSump Soil Character: PE Sc Received Chec Amount Permit/ Date Invoice # Permit ID# Code INFO BKn s lRemitted Service Request # d,2104W2:� 1 cS(Z p 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17