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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE FERMI (;ALL (--0,953-71597 FOR INSPECTIONS TIQ' JOB ADDRESS I I ,- 1 o& ` CITY/ZIPII :;ROSS STREET APN 2� V - 2 1 OWNER NAME M i AAQ CIA OWNER ADDRESS G� L �� D t VrV �-b— 'l aY V C /L ' `��CITY%STA CONTRACTOR CONTRACTOR ADDRESS LICENSE I I C-42 1 I C-36 OTHER PHONE PARCEL SIZE t/. 0 2— PHONE Lb ��rfTz*0 CITY/STATE/ZIP NUMBER EXPIRATION DATE 7 II�-I WATER TABLE DEPTH: � ft GEOGRAPHICAL INFORMATION: COO dlnateS X Y J PERC TEST # BUILDING PERMIT #LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION RILPAIWADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL J OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: � ^ NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY _I l�VL7 gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL l �O ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LI LEACH LINES LEACHING CHAMBERS # OF LINES S LENGTH OF LINES �� ft Amount emitted Date DISTANCE TO NEAREST WELL ft FOUNDATION L6 ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft s�t�7�sq 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 SEEPAGE PITS NUMBER ? WIDTH k2_ ft DEPTH ft DISTANCE TO NEAREST WELL L S0 1 ft FOUNDATION c I` V 1 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. SIGNED A N/\/ TITLE I1 _ _ DATA. —S EPARTMENT S D Application Accepte,4*4j, Date��/Area Fmpinvee ID# Ale- q - Final Inspection By`� Date ,z3f l�5 C SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC INFO Received B eck#/ Amount emitted Date Permit/Code Service Request # Invoice # Permit ID# 4?41 c 46R02- S `-3 s�t�7�sq 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 c�