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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-REFUNDABLE PERMITGALL 209 953-7697 FOR INSPECTIONS JOB ADDRESS;917W) CITY P CROSS STREET C'�� APN OWNER NAM LXPIRES 1 YEAR FROM DATE ISSUEI ) a, fA- PARCEL SIZE _ PHONE (7 - � �� OWNER ADDRESS _CITY/STATE/ZIP G CONTRACTOR %4j171 V tk4 PHONE ?2 L CONTRACTOR ADDRESS ,�31G 6 _CITY/STATE/ZIP/ /dr. �6& LICENSE ❑X-42 Li C-36 OTHER NUMBER v _EXPIRATION DATE 7 1,7 f PERC TEST # 1 BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPLACEMENT L1 FORMATION: Coordinates X Y LAND USE APPLICATION # REPAIR/ADDITION ENGINEER DESK OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION _ NED /ALTERNATIVE INSTALLATION WILL SERVE: I._I RESIDENCE ❑ COMMERCIAL I _I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CY1 W -4h 40K 7C4 CAPACITY _ _ gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY _ _ gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL it FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) `! LEACH LINES I I LEACHING CHAMBERS # OF LINES I I LENGTH OF LINES YO it Permit/ Service Re ues Invoice # DISTANCE TO NEAREST WELL it FOUNDATION 30 1 ft PROPERTY LINE 30 ft ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH it LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH _ ft LENGTH it DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft _ SEEPAGE PITS NUMBER 7 WIDTH -' ft DEPTH �LS ft DISTANCE TO NEAREST WELL /5� ft FOUNDATION �bCJ ' 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. Application Accepted By Final Inspection By Character of Soil to Dept f 3 COMMENTS .•tel•, i Vn 11Y1z7r-11__li 11ww17 / - r-L.CMJG a.ni-a- {cyJ/zwo-1U.71 TITLE `i�s'fi-t r' % DATE & -2,6-69 TME N T U5E UNLY Date I Araa Employee ID# Date_ ❑ SPECIA PERMIT -Approved by Pit/Sump Soil Character: U PE Code SC INFO Received B CE ash Amount Remitted Date Permit/ Service Re ues Invoice # Permit ID# 2 j� a/i � ori yCa 44I,� p j'►vow 1 iw v i � ` >atcav� w Ffh. J n� IM--/ 1 r 42-01 �/ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17