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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 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSJACk 11 6Z IbP CITY/ZIP j 065--Nn_ 3 D 4• $ CROSS STREE`�/� .�� m �/^� APN � PARCEL SIZE +-7T 59 OWNER NAME V i.L6f_ 1 L� L( J PHONE ��O^�� v LLD 7 OWNER ADDRESS J CITY/STATE/ZIP LLD i { ZA-0 CONTRACTOR • A -./�/�� l WSHONE 6-C�6= CONTRACTOR ADDRESS VLJ`! �J CITY/STATE21P LICENSE )�, C-42 I I C-36 OTHER A NUMBERIOn 511 EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: Y RESIDENCE 1.1 COMMERCIAL ._I OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFGGA l�j& CAPACITY 12 X — gal #OF COMPARTMENTS 2- ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS �-�r i DISTANCE TO NEAREST: WELL 1 1 ft FOUNDATION } ft PROPERTY LINE CDU ft ❑ LIFT STATION SIZE TYPE OF PUMP 0 PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES X LEACHING CHAMBERS S !A #OF LINES / LENGTH OF LINEs Q ft DISTANCE TO NEAREST WELL�� ft FOUNDATION10 ft PROPERTY LINE I90 ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH PAVAso. .(t GIS I ANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE1117�ft El MOUNDED WIDTH ft LENGTH ft DEPTH t 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 r JOA-RA VIN C �.._ft C3DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH HEA ENTA ft { DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ENrft A.I SEEPAGE PITS NUMBER WI TH _ ft DEPTH ft 1 DISTANCE TO NEAREST WELL -5n , ft FOUNDATION I ft PROPERTY LINE Ayn 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 COMP EN TION LAWS. rMhVfiwM1V110 lfflff O ICE REQUIRED FOR MtECTIONS-PLEASE CALL 209 953-769 SIGNED TITLE DATE (X� ''' •+,.,. r e•+.'"'r..'..---.. - «,,. fid-_ h �r; f`` f r,l s 's *yam Application Accepted By Date Area Employee IDti Final Inspection By Date 7_�Z K 101 SPE CIAL PERMIT-Approved by Character of Soil to D pth o 3 Pit/Sump Soil Character: COMMENTS PE SC Receiveda Amount Permit/Code INFO B s emitted Date Service Re uest# Invoice# Permit ID# 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 fi