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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 -REFUND BLE PERMI CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ JOB ADDRESS S �'f-�'�G' CITY/ZIP C, Y CROSS STREET DISTANCE TO NEAREST: WELL �/J�' APN _3 1T-� PARCEL SIZE v OWNER NAME V-nia + PHONE OWNER ADDRESS 45� �4%t! A=4• CITY/STATE/ZIP 1 ��/. 1 Gy� -{ 3 n M� CONTRACTOR d'Q-!S!'C X � &C-, /• PHONE CONTRACTOR ADDRESS RsACIIk DISTANCE TO CITY/STATE/ZIP ! '!�` / �✓� /�J �7 LICENSE 11 C-42 I I C-36 OTHER ft NUMBER EXPIRATION DATEi�/ I L �T NEAREST ft FOUNDATION ,.�— ver 1n. R u CUUnArnikAL inrvnmA I IUIV: VUU1U111dl65 A 1 PERC TEST # BUILDING PERMIT #Ap 0 U / a 3 LAND USE APPLICATION #_ TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DES[ REPLACEMENT 0NT-0E-SFRVICF RFPTIC RVSTFM I I nFSTRI ICTI(NJ INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: S NUMBER OF EMPLOYEES: TERNATIVE W' SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS NEAREST DISTANCE TO NEAREST: WELL �/J�' ft FOUNDATION ��w ft PROPERTY LINE �b ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) U --"LEACH LINES LEACHING CHAMBERS # OF LINES � LENGTH OF LINES 10'-%n ft WELL ft FOUNDATION 10 I ft PROPERTY LINE 7s� ft ft DISTANCE TO NEAREST FILTER BED WIDTH DEPTH ft WELL DISTANCE TO NEAREST MOUNDED WIDTH ft PROPERTY LINE ft It DISTANCE TO NEAREST SUMPS WIDTH DEPTH ft WELL DISTANCE TO NEAREST DISPOSAL PONDS WIDTH 16 ft PROPERTY LINE ft DISTANCE TO NEAREST SEEPAGE PITS NUMBER ft DEPTHj-�- T ft DISTANCE TO NEAREST # OF LINES � LENGTH OF LINES 10'-%n ft WELL ft FOUNDATION 10 I ft PROPERTY LINE 7s� ft ft LENGTH Received B hec sh ft DEPTH ft WELL Invoice # ft FOUNDATION /I ft PROPERTY LINE ft It LENGTH ft DEPTH ft WELL It FOUNDATION 16 ft PROPERTY LINE ft ft LENGTH ft DEPTHj-�- T ft WELL ft FOUNDATION ft PROPERTY LINE Y ft . ft LENGTH ft A DEPTH ft WELL ft FOUNDATION ft PROPERTI mow! ft WIDTH ft DEPTH FN QVIN o-0 •. - ft WELL ft FOUNDATION ft PROPERTY L,r� 62niA( 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 COMPEN /ITION LAWS. MINIMUM BOU-RADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 SIGNED _ TITLEDATE DEPARTMENT USE ONLY q nn Application Accepted ByMju� Date 5- Area / Employee ID# A;n revl Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: a PitlSump Soil Character: COMMENTS PE CodeINFO SC Received B hec sh Amount Remitte�h�spoorlj'C5 Date Permit/ Service Reguest # Invoice # Permit ID# oZ /I SS/ 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17