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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT T ✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS 7 t a --Ik �1 • • • wA �y K�J f -,"1 j I CITY/ZIP wrQ""7G'L Tom �� n • .r CROSS STREET 13 me APN 0 V PARCEL SIZE 3 M I I t `4 S OWNER NAME IVA ch I L Or 1 PHONE #OFCOMPARTMENTS� CC OWNER ADDRESS G �'r CAPACITY gal A CA WIDTH DISTANCE TO NEAREST: WELL i o� ✓ __CITY/STATE/ZIIP�xry it PROPERTY LINE #'%3' ft Mme+ CONTRACTOR YI �� (CG5 C,�, MGIC 4,..*-4,..*-.�'f _ PHONE Li.��ry ❑ MOUNDED CONTRACTOR ADDRESS _ yX %Sad CITY/STATE/ZIP kni-4�01-1 4�5 ��(,�• LICENSE I I C-42 C-36 OTHER ICa/ 12, ❑ SUMPS WIDTH NUMBER EXPIRATION DATE WATER TABLE DEPTH: ti I G ft GEOGRAPHICAL INFORMATION: PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/ADC Coordinates X Y LAND USE APPLICATION # IN ENGINEER DESIGNED REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: IIRESIDENCE LL COMMERCIAL LL OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS:5 NUMBER OF EMPLOYEES: TERNATIVE 7 U—' SEPTIC TANK TYPE/MFG P�-L CAPACITY I.).wa gal #OFCOMPARTMENTS� ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS WIDTH DISTANCE TO NEAREST: WELL i o� ✓ ft FOUNDATION I O d ft PROPERTY LINE #'%3' ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES r ft ch--- eck#/ DISTANCE TO NEAREST WELL l�T� ft FOUNDATION 0 t ft PROPERTY LINES � ft ❑ 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 WIDTH ft LENGTH It 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 D ---'SEEPAGE PITS NUMBER WIDTH 'L�-�I ft DEPTH a-tT 11 ft DISTANCE TO NEAREST WELL ft FOUNDATION PROPERTY LINE �S/ 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. 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - SIGNED _ Application Accepted Byy/ / U�� Final Inspection By X i' Character of Soil to Depth of 3 Ft: COMMENTS DEPARTMENT USE ONLY ' I � Date – Area Employee ID# �h Me�� Date 2K f ❑ SPEC'IA'L PER/MIT - Approved by Pit/Sump Soil Character: PE Code Sc INFO Received ch--- eck#/ Amount Remitted Dat Permit/ Service Request # Invoice # Permit ID# 4xil 117I 1 00"79.71 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 U 4 Y v