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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT PAY ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVUN-11EFUNDABLE PERMIT GALL ZU9p 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS r T (� a ` pQ CITY/ZIPO CROSS STREET W APN �v r I O r/j PARCEL SIZE OWNER NAME CMCJ GLp II Cp ,,J a } �yPHHON a09)` QA ayC� J1-1 a OWNER ADDRESS HtS� 5L4 -a -Q I�.IA CITY/STATE/ZIP IY'Wl L sci I �/`� !O CONTRACTOR CONTRACTOR ADDRESS LICENSE I C-42 I 1 C-36 OTHER PHONE CITY/STATE/ZIP NUMBER EXPIRATION DA WATER TABLE DEPTH: IDS ft GEOGRAPHICAL INFORMATION: Coordinates X Y _l PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 't NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION LOA 16 INSTALLATION WILL SERVE: 0� RESIDENCE 1_1 COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: .J_ /1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: A. SEPTIC TANK TYPE/MFG P L CAPACITY (p_ 0 gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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 Character of Soil to De th of COMMENTS6/13A2 I 642%/x C Q v ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953 TITLE O W 11 '4-' r DATE - 'Ib,, DEPARTMENT USE ONLY Date 16- 11 Date Pit/Sump Soil V d ` -- se A . _ I / _ A AreaU / `/� Employee ID# wof ❑ SPECIAL PERMIT - Approved by N PE Code LEACH LINES LEACHING CHAMBERS # OF LINES `�' LENGTH OF LINES L-I!'� , " ft Date Permit/ Service Request # DISTANCE TO NEAREST WELL t O O ft FOUNDATION 0 ft PROPERTY LINE -F ft �t 0 ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL _ ft FOUNDATION it PROPERTY LIN �-a-� ft r MOUNDED WI i H ft LENGTH ft DEPTH V G � ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN -}�n� ft ❑ SUMPS WIDTH ft LENGTH 'AY :h1 i ' U LY IV ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ENVIRONMENTAL ft DISTANCE TO WELL ft FOUNDATION ft PROPERTY t INE ft 41 SEEPAGE PITS NEAREST NUMBER o</ WIDTH 3 ft DEPTH A5 ft DISTANCE To NEAREST WELLj !>1 ft u''11 FOUNDATION -T V ft PROPERTY LINE 45 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 Character of Soil to De th of COMMENTS6/13A2 I 642%/x C Q v ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953 TITLE O W 11 '4-' r DATE - 'Ib,, DEPARTMENT USE ONLY Date 16- 11 Date Pit/Sump Soil V d ` -- se A . _ I / _ A AreaU / `/� Employee ID# wof ❑ SPECIAL PERMIT - Approved by N PE Code SC INFO Received Check#/ By Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 4 4 S 5 (6 SR9l l kseX-- or- ISR--- do &"'u#A:tr 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17