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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT I �e✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP a CROSS STREET WILIV APN IO�J iy•S PARCEL SIZE C OWNER NAME I'f Q�ffi Y-ag H a C0 u PHONE 70 OWNER ADDRESS �+� t�>r4-o/ V 1 CITY/STATE/ZIP led; CONTRACTOR �GJ fl��Ir(i _ � jC- PHONE � ` /�j�/ CONTRACTOR ADDRESS 7 145- . / CITY/STATE/ZIP ✓6 PA LICENSE 1 . C-42 ❑I C-36 OTHER NUMBER XPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y Fl PERC TEST # BUILDING PERMIT# D LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMER ,/ El OTHER CIA NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: v NUMBER OF EMPLOYEES: 4�9--SEPTIC TANK TYPE/MFG Z-- CAPACITY A 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) 7 LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL 0'0 ft FOUNDATION D 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 P.avAa,..._ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEF?ft ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH CU ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE FPI 2 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI IV�1JOAQUIN ^��■�,__ ft SEEPAGE PITS NUMBER �7 WIDTH 4� ft DEPTH GSL 8 NMEN`TA'L,�T ft DISTANCE TO NEAREST WELL d , ft FOUNDATION �l� ' ft PROPERTY LINE S� GWENT 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. MINIMUMal 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-76697 SIGNED _ TITLE DATE tt 17 1 —46 ti D PARTMENTUSEONLY Application Accepted By Date "� Area n Employee ID# 1j (n�R Final Inspection By A I d i eQ'- ` Date 9' ?Z Ile ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS r C �n- PE SC Received Amount Date Permit/ Invoice# Permit ID# Code INFO By as Remitted Service Request# zl 1 117 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17