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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN J04QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE PERMIT,, C:ALL LU`J `JS:i-/b5/ FOR INSPECTIONS tXPIRESS I YEAR FROM UATE ISSUEI JOB ADDRESS j/L 4A iV-e, CITY/ZIP �;�Tf\,C.A Amount Remitted �4'C �17=`�– gal # OF COMPARTMENTS ❑ �- CROSS STREET IW I APN , / PARCEL SIZE / OWNER NAME L Q a dt n r d C c� n an a d ) PHONE WELL OWNER ADDRESS P son I U SS CITY/STATE/ZIP P- C1 7 S J b CONTRACTOR in : 9Lti1-S l�tG�� .SYS _ PHONE ❑ PKG TX PLANT CONTRACTOR ADDRESS lam' SAND OIL SEPARATOR (ENCLOSED SYSTEM) CITY/STATE/ZIP 4—'-r/4 ❑ LICENSE 1 1 C-42 LI -C-36 OTHER NUMBER _ EXPIRATION DATE ! ii LENGTH OF LINES ft WATER TABLE DEPTH: 5 ft GEOGRAPHICAL INFORMATION: Coordinates X Y I PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION ❑ SEPTIC TANK TYPE/MFG hec ash Amount Remitted CAPACITY Permit/ Service Request # gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL It I FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTH 10 ft LENGTH ��% It DEPTH 11 D ft DISTANCE TO NEAREST WELL IIjy?' ft FOUNDATION h:SI ft PROPERTY LINE S ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Ift A ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN Ilaft w ❑ DISPOSAL PONDS WIDTH ft LENGTH ft WSJ ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE4UU 2 20Mft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH1'IMAIP(w -Ulu ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER] R Vry It I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT?116AN 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 COMPEN§QTION LAWS. MINIMUM T OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)).9.53-7^697 (� SIGNED TITLES t -'I 1 r DATE 1 O Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS F t 'U A proyc, I ((- r.�. . . . . DEPARTMENT RTMENT USSEE O-NLY 6. DateArea Ljj& , Employee ID# ) Date -/22r 1-1 SPECIAL PERMIT -Approved by IUSump Soil Character: on i1 i Inti �rr PE Code SC INFO Received BY,,n hec ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 300 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17