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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT /5 '""' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NGN-KEFUNDABLE PERMIT (:ALL 2U9 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI 10171-11LJOB ADDRESS '2j; (/ Z f' �K res- �I� CITY21P �1 �D ��77 i QROSS STREET lcr 0+-' A^PN ' _� q 2 PARCEL SIZE OWNER NAME S/ CIL, /�� ^Imb e Il� PHONE OWNER ADDRESS n.`3'24Z j� (�S 1? ,,r ! �I , CITY/STATE/ZIP --;7, CONTRACTOR 1314 IJ` p yo S�Ut.' !/i PHONE 64 W Z� r CONTRACTOR ADDRESS �O JU ;Z�ot /� _CITY/STATE/ZIP ��' �A LICENSE I I C-42 I I C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 11 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: X RESIDENCE I] COMMERCIAL � CI OTHER /� NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: "T NUMBER OF EMPLOYEES: ❑ ❑ SEPTIC TANK GREASE TRAP LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL ft SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS FOUNDATION ft PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) Amount Remitted LEACH LINES kEACHING CHAMBERS oe # OF LINES LENGTH OF LINES ' OyO ft DISTANCE TO NEAREST WELLt" �'_�f ft ` ^ FO FOUNDATION '[L ft PROPERTY LINE �l/T ft o ❑ 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 ❑ SUMPS W,DTH ft LENGTH ft DEPTH YM�..._ ft DISTANCE TO NEAREST WELL ft FOU14DATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEJUN J2 It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH SANft DISTANCE TO NEAREST - ---- .... WELL ft FOUNDATION ft PROPERT�j�A':J/N COI INT,_ ft e � �.. orvr _,,, UEP,gRr„1c I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE �W1'N *AN 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 topept , of 3 COMMENTS _ 1[ P_rs4 TMENT 14SEk&hL Y Date Area Employee ID#1�- Date ❑ SPECIAL PERMIT - Approved by �� S Pi_USump oil Charact 10— QTY SVD 0- - I A li-c (—C /}IYIP AI P PE Code SC INFO Received B Check# Amount Remitted Dto Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17