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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-HEFUNDABLE PERMIT GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS &)-I 7'AQero5 CROSS STREET Ho'r ►ger OWNER NAME G`�''��"��^► OWNER ADDRESS I IE' e �l CITY/ZIP J30 C� FC�i1 95 2 lS , J APN I S I - 11PARCEL SIZED / PHONESIc) ✓ -SCo _ IS CITY/STATE/ZIP Sa4L -z CA Sts -1-7 � `J` �/ F�A� LLC ` fin � ' DISTANCE TO NEAREST CONTRACTOR r ft PHONE ft LENGTH DISTANCE TO NEAREST CONTRACTOR ADDRESS ft CITY/STATE/ZIP ft LICENSE ❑ C-42 F� C-36 OTHER NUMBER EXPIRATION DATE_ WATER TABLE DEPTH: ti 7 ft GEOGRAPHICAL INFORMATION: Coordinates X Y Ll PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION i i REPAIR/ADDITION i I ENGINEER DESIGNED/ALTERNATIVE I REPLACEMENT _- I' OUT -OF -SERVICE SEPTIC SYSTEM /Xi DESTRUCTION -44 -Cc 1 O"k INSTALLATION WILL SERVE: ❑ RESIDENCE U COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTICTANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY - __- CAPACITY ft FOUNDATION ❑ PKG TX PLANT ❑ LEACH LINES P LEACHING CHAMBERS _ # OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ❑ FILTER BED WIDTH _ - _ ft LENGTH DISTANCE TO NEAREST WELL ft ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft ❑ DISPOSAL PONDS WIDTH ft LENGTH 9Z gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) tt ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION -- - ft DISTANCE TO NEAREST WELL ___ ft FOUNDATION ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE To NEAREST WELL ft FOUNDATION LENGTH OF LINES ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE It DEPTH ft ft PROPERTY LINE ft DEPTH ft 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. SIGNED Application Accepted By Final Inspection By no Character of Soil to Depth of Ft: COMMENTS A 14,AC h in O AA'A 'Vr1 /IYJrGV IIV/YJ - VP1L1- JGV.7/ .7.JJ-/V.7I TITLEOw� qR-; — DATE L l - �{ DEPARTMEN USEONLY Date Area Employee ID# h G T Date 6 Cl SPECIAL PERMIT - Approved by PiUSump Soil Character: S wp. - PE Code SC INFO Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17