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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P""' SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVUN-FitFUNDABLE YERMII GALL (2U.9).953-1597 FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS / C;PL1� .� yl ��/ U 1 � %J06?r-a 1-40ae7 ---.-----j-CITTYY//ZZII%P� L -0i 1 � �V CROSS STREET �I T IL - o ►r 1 TrOC�dA APN✓ C/,/ V PARCE SIZE OWNER NAMEI� I��C �e I C, j ( PHONE +5 -,P(a' - /' J 7 OWNER ADDRESS Izt-7 p14--CITY/STATE/ZIP 1'0PI 1 `7� CONTRACTOR ' )�"I I Y -C. PHONE,:): 0 � ! - .(K ` �% SO -)-7 CONTRACTOR ADDRESS ��, bS0 ✓J Dr% CITY/STATE/ZIP LICENSE I XC -42 ❑ r C-36 OTHER NUMBER 4"EXPIRATION DATE WATER TABLE DEPTH: ( U `Ga ft GEOGRAPHICAL INFORMATION: Coordinates X Y "O 1 PERC TEST # TYPE/MFG BUILDING PERMIT # LAND USE APPLICATION # gal # OF COMPARTMENTS T TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNELTERNA I REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION ff D INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL LI OTHER N✓ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPL&A •V/ROA�/�C01,-. i LEACH LINES LEACHING CHAMBERS Ate` ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS T ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ��71� DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) i LEACH LINES LEACHING CHAMBERS # OF LINES I LENGTH OF LINES J� o ' ft Date Permit/ Service Request # Invoice # Permit ID# �25DISTANCE I ��71� TO NEAREST WELL 100 ft FOUNDATION ft PROPERTY LINE 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 ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDAHON ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft IxDISTANCE SEEPAGE PITS NUMBER 3 WIDTH � ft DEPTH e�S ft TO NEAREST WELL /In , n ft FOUNDATION Cq0 , ft PROPERTY LINE /Q 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. MINIMUM�HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE r DATE D PARTMENT USE N Y //%%9��%% Application Accepted B Date Area L�Li Employee ID#_AA Final Inspection By 6ZIq-q /Yte Date z ❑ SPECIAL PERMIT -Approved by r Character of Soil to Depth d3 Ft: Pit/Sump Soil Char r: COMMENTS LJ--' L-.i..1�n! J �IU' PE Code SC INFO Received B C Cas Amount emitted Date Permit/ Service Request # Invoice # Permit ID# o I ��71� 31I 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 7,, N s