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ONSITE WASTEWATER TREA-rMENT SYSTEM PERMIT VO /' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT T GALL 209 953-7697 FOR INSPECTIONS (� LXPIRES 1 YEAR FROM UATE ISSUE[ JOB ADDRESS �G� LI 1i C i V, ^� , - CITY/ZIP \ NC""r �� CROSS STREET V1(V e%\ r' APN CL — Fea - tk`1� _ _ __ PARCEL SIZE r OWNER NAME �f: 3%1 C & t e �M I/cha�e.j r i' Debra s Gram ?ptIONE OWNER ADDRESS 6535 � ` t�\� Ej `J ovp , A"~ Co CITY/STATE/ZIP CONTRACTOR VJ ES 77 CA�A,�Sv r " RL`�I�/ IAJ( PHONE CONTRACTOR ADDRESS SS 1 `7� �1 S( G� y � CITY/STATE/ZIP _ 1 �D 7� C^ C) LICENSE I C-42 ❑LIC -36 OTHER NUMBER v IIS/- ! EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL I C PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION TION: COOrdi tes X Y AND USE APPLICATION # VADDITION IFENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I i DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: r CFPTIC TANK TvPF/MFr, �� L CAPACITY 124M oal # OF COMPARTMENTS ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG soDISTANCE TO NEAREST: WELL o SIZE TYPE OF PUMP CAPACITY _ gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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. MINIMUM 24 U V CEAtOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE �t� _ _ DATE Application Accepted By-- Final Inspection By,M4 Character of Soil to Depth COMMENTS ,L Y Area Employee ID# LI SPECIAL PERMIT - Approved by Soil Character: k" to PE Cod SC INFO Received /IlCheck#0 ` Date y Invoice # ❑ LEACH LINES LEACHING CHAMBERS INJIf khIAETSJ _ # OF LINES LENGTH OF LINES 1 It DISTANCE TO NEAREST WELL SCI` It FOUNDATION _�f it PROPERTY LINE 1 1 ft ❑ FILTER BED WIDTH ft LENGTH __ ft DEPTH ft DISTANCE To NEAREST WELL It FOUNDATION —ft PROPERTY LINE ft ❑ MOUNDED WIDTH _ ft LENGTH _ ft DEPTH tt DISTANCE TO NEAREST WELL_ ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH _ ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY L ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH IY,-T Q1, ft ft ft PROPE/R�TYLINEy r!uN C'Q ft JbL SEEPAGE PITS DISTANCE TO NEAREST NUMBER WELL WIDT', H FOUNDATION ft DEPTH `5 '�RTTgC ft DISTANCE TO NEAREST WELL I %Na ft FOUNDATION _ ft PROPERTY LINE S N% 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. MINIMUM 24 U V CEAtOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE �t� _ _ DATE Application Accepted By-- Final Inspection By,M4 Character of Soil to Depth COMMENTS ,L Y Area Employee ID# LI SPECIAL PERMIT - Approved by Soil Character: k" to PE Cod SC INFO Received /IlCheck#0 Amount ARemitted Date Permit/ Service Request # Invoice # Permit ID# q!ik _�f 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T L -J G L7