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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOA0MNrOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NOF -0 -REFUNDABLE PERMIT (:ALL (ZU.9) JbJ-/by/ FOR INSPECIIUNS CXI'IHtb I T tAH FHUM UAI t IJJUtI JOB ADDRESS ,`` ,,) 1 [N � � CITY/ZIP �t� C CROSS STREET Amount emitted APN a 13 3 3 Oi J PARCEL SIZE OWNER NAME Permit ID# - _ PHONE 70— C DISTANCE TO NEAREST WELL OWNER ADDRESS _ SC) ene) _ --CITY/STATE/ZIP ft PROPERTY LINE ft CONTRACTOR 4�44 �rol vel ` �T�"1 �1 C _ PHONE t b e7 r J CP � � S� o% % CONTRACTOR ADDRESS c? / 4e ey roy► e- • _ CITY/STATE2 C..!1P t , `. LICENSE 1 C-42 1 1 C-36 OTHER NUMBER _'S-5r%y� EXPIRATION DATE ( _ -? / �! WELL 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 DESK NED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL ElOTHER NUMBER OF LIVING UNITS: 'I/ NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ CAPACITY Igo O gal # OF COMPARTMENTS / CAPACITY gal # OF COMPARTMENTS Amount emitted DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS I10 C tt"'f b" # OF LINES Sc INFO LENGTH OF LINES �T� , ft eck Amount emitted Date Permit/Code Service Request # , Permit ID# 1424 70— 224q DISTANCE TO NEAREST WELL / Q0 ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It 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 WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 SEEPAGE PITS NUMBER WIDTH 3 / ft DEPTH Z;161 ft (\ DISTANCE TO NEAREST WELL iSD ft FOUNDATION _ ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPL!CATION 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 WIT I ALL WORKERS COMPEN$AIION LAWS. MINIMUM:arHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED l TITLE 4 DATE Y —18 —/y DEPARTMENT .E Y Application Accepted By Date Area Employee ID#� Final Inspection By Date ��d ❑ SPECIAL PERMIT - Approved by Character of Soil to Dep of 3 t: ---/ / Pit/Sump Soil Character: COM JylEN S R 1746h I n� ^� A S1 a Ile Ir %h I P rk-i-oIra PE Sc INFO Received B eck Amount emitted Date Permit/Code Service Request # Invoice # Permit ID# 1424 70— 224q S 42-01 5/5/17 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT M Y 0