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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 Iyurv-rf::rUNUAtILt YLHMIT (:ALL (ZWY 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOS ADDRESSCi,+J�� CITY21P rjMn A GA 55-33 CROSS STREET C4 n.J, n APN 2 2A 3 k)1 1 1 PARCEL SIZE 3 OWNER NAME �1 u s PHONE OWNER ADDRESS ' �/ 7 Sm e SS CITY/STATE/ZIP tj n4l /� a 2 CONTRACTOR y • .IfILt �S &ZC 4 Se r PHONE i4 sz, ,�� - & t r^ CONTRACTOR ADDRESS �� n& &�►'' I6 CITY/STATE/ZIP r�,`A 16-3X LICENSE I I C-42 11! C-36 OTHER A NUMBER (0,x 575V EXPIRATION DATE I .)- ( g WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION 1 PERC TEST # BUILDING PERMIT # _ TYPE OF WORK: NEW INSTALLATION &e- REPAIR/ADI Coordinates X Y_ LAND USE APPLICATION # IN ENGINEER DESIGNED REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: iu/RESIDENCE ❑ COMMERCIAL L OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: _3 NUMBER OF EMPLOYEES: ,TERNATIVE ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS 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 # OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft / � B' FILTER BED WIDTH i�7I ft LENGTH LI ft DEPTH 19 � ft DISTANCE TO NEAREST WELL_4�b1 ft FOUNDATION 161 ft PROPERTY LINE �,5� 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 It 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 ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION 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. Iva MINIMUM a# H04IR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE DATE"9'* r�j W DEPARTMENT USE ONLY Y24 1 / Application Accepted By ` Date )l / Area qqMIJI4 Employee ID# I,.1rw Final Inspection By ^ Date / SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTSr 01 e�[:, G (f pr✓vuI PE Code SC INFO Received B hec ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# ,1 1 U I S U C) � Z4 -i "1 D 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17