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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTDEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFONDABLE PERMIT L I �� 0 77 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I A a % �� 1 1 r) 't""r1L, X ( I 'Lir 1 _CITY/ZIP Mn 1r-0 CROSS STREET 7 i�:� APN�"��i j PARCEL SIZE ' OWNER NAME nw �Il4Yk!'I /1C jj4'9 DESTRUCTI AQUIN PHONE OWNER ADDRESSjy\ !. �� 1 i •!) � l'n Q CITY/STATE/ZIP 0/ I -CA CONTRACTOR ill -it ��%rS o)Ct�I?;Z� /� E -C i . PHONE Li Cr'ti�OLIJ CWtEPTIC TANK CONTRACTOR ADDRESS i %1 1.�lyL co j CAPACITY l I0 5'ci CITY/STATE/ZIP f ync^v_- A ',fes ' ! 5 ' LICENSE ❑ ❑C-42 I I C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: , ft GEOGRAPHICAL INFORMATION: Coordinates X SIC - Y /VE� ❑ PERC TEST # WELL ft BUILDING PERMIT # LAND USE APPLICATION it 05 TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEEi w"61ED/ALTE E ft DEPTH ft REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTI AQUIN INSTALLATION WILL SERVE: �/SIDENCE ❑ COMMERCIAL ❑ OTHER TH DE T ft LENGTH ft DEPTH ft DISTANCE TO NEAREST NUMBER OF LIVING UNITS: li NUMBER OF BEDROOMS:� NUMBER OF EMPLOYEES: CWtEPTIC TANK TYPE/MFG j CAPACITY l I0 5'ci gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ft LENGTH DISTANCE TO NEAREST: WELL ��1"� ft FOUNDATION Ali ft PROPERTY LINE a`J� ft ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ��,1)y ft hec ash DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 11 f ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft MPS f WIDTH ft LENGTH to , ft DEPTH 0 ft DISTANCE TO NEAREST WELL I %2 ft FOUNDATION _101 ft PROPERTY LINE Ih ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION 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. ADVANCE NOTICE REQUIRED FOR INSPECTIONS - SIGNED �, — _ TITLE _ it RLQ DATE Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS Jae vlvL r Q Area Employee ID# ✓ 1 ii / ! Z ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE Code SC INFO Received B hec ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 1 I ► o/ s S 51+� - Ott 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17