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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Q r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVUN-MEFUND BLE//PERMIT (;ALL ZUy yb3-/ 97 FOR INSPECTIONS ,q/� EXPIRES I �YEAR�FjROM DATE ISSUEI JOB ADDRESS y� LJ S CITY/ZIP I• •G�✓1' i�]� j 64- q !s; '� It" CROSS STREET I 1 or -K LC.L..i.�?a APN 1 1;,(.) -7PARCEL SIZE o OWNER NAME -r4 � � f / ^ `l i r -w PHONE (� 2 OWNER ADDRESS �� ' �LI r� "�)'S)d Lie\ CITY/STATE/pZlPyy/rF-+�Y�ea�+ Ne -1 CONTRACTOR x, 5_ 1 L �a7L�` - PHONE 6 , &ASK'dl 3(�S� �p c� CONTRACTOR ADDRESS -w J CITY/STATE/ZIP �T A _&'GA l e4 LICENSE C-42 1 I C-36 OTHER NUMBER EXPIRATION DATE / l� �r WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y J PERC TEST # BUILDING PERMIT # "LAND USE APPLICATION # TYPE OF WORK: /NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION Tan 1C INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 1-1 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: y NUMBER OF EMPLOYEES: '0/S`EPTIC TANK TYPE/MFG CAPACITY .30 nz) gal # OF COMPARTMENTS C+� ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS WIDTH DISTANCE TO NEAREST: WELL * ft FOUNDATIONS i ft PROPERTY LINE �.'�/ ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) $ LEACH LINES LEACHING CHAMBERS Receivedhec B # OF LINES LENGTH OF LINES •clJ ft Date I I j DISTANCE TO NEAREST WELL FOUNDATION t ft PROPERTY LINE �3 t It ❑ FILTER BED WIDTH ft LENGTH o' ft DEPTH ft 5" b a) 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 ❑ SUMPS WIDTH ft LENGTH ft DEPTH RCA._ Tft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE lftft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTHft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH '.QUIN r+..,- ft DISTANCE TO NEAREST WELL ft FOUNDATION H�E,� ft PROPERTY IPLTH n MYMENTA", I ' 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 - t �/ TITLE CJS (�IKs �-�M� DATE Application Accepted By / I VG Final Inspection By e�e Character of Soil to Depth of 3 Ft: COMMENTS DEPARTMENT USE ONLY Date i3-- Area 309 Employee ID#A h tw Date 1?T Ci SPECIAL PERMIT -Approved by Pit/Sump Soil Character: PE Code SC INFO Receivedhec B ash Amount Remitted Date I I j Permit/ Service Request # Invoice # Permit ID# 4a, t o I I S o' 1 5" b a) 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17