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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAO1,1IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZF.LTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 KION -REFUNDABLE PERMIT CALL (209 953-7697 FOR INSPECTIONS EXPIFROM UATE ISSUE r / - y JOB ADDRESS '7nn��y�ppO `' `�/ E'1` 908D -CITY/ZIP b1G ,RES 4A '?!5 /V .Ott �� ZI S 'L` CROSS STREET /I'//"l91 PLOA RIOFkD APN I � � IQ a % � PARCEL SIZE 01 7 fa /kT 411:2W 5o 45eW1 Py- ft PHONE 2-0q-519-215'93 OWNER NAME WELL It - OWNER ADDRESS /53.7-7 Sy' ��P A 3 0 CONTRACTOR _ PHONE DEPTH CONTRACTOR ADDRESS !l _ __ CITY/STATE/ZIP WELL LICENSE n 0-42 [- C-36 OTHER FOUNDATION NUMBER _ _ - _EXPIRATION DATE _ WATER TABLE DEPTH: 7 G` (! ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # _ LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED REPLACEMENT 11 OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: I RESIDENCE ❑ COMMERCIAL J ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 1 NUMBER OF EMPLOYEES: TERNATIVE D SEPTIC TANK TYPE/MFG _ P �- L CAPACITY I �V �% gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG __ CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION It PROPERTY LINE _ ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES X LEACHING CHAMBERS Received B # OF LINES 3 LENGTH OF LINES �C) ft Invoice # Permit ID# V110i N 12 21-3 X ft 3 DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE _ ❑ FILTER BED WIDTH ft LENGTH ft DEPTH !l DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It 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 _t'ft FOUNDATION ft PROPERTY LINE ft y� SEEPAGE PITS 2 NUMBER J WIDTH_ 14 ", ft DEPTH 15' ft DISTANCE TO NEAREST 7 WELL �_ I _� It FOUNDATION _L U It PROPERTY LINE ft I HEREBY CERTWY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNT`; 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 COMPENSVION LAWS,/ VANCE NOTICE REOUIRED FOR INSPECTIONS - SIGNED _ _/ / 1\,O E // _ TITLE (/w/V G K DATE Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS DEPARTMENT USE ONLY date .2 VAI Area _j J q_ -1_ Employee ID;: Date ❑ SPEC!AL PERMIT - Approved by 1PIt/Su1mp Soil Character: -- r f/ ^ f z, r n1 .� a lo 4, 1) ei �, h ) r 4 -el ✓ e e 4 C(4 #-r,,,1 PE Code SC INFO Received B Check a h Amount Remitted Date Permit/ Service Request Invoice # Permit ID# V110i l 21-3 X 3 - - - 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 Y v C Z fi I