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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 -REFUND PERMIT CALL FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �9)953f-76 1�1� _VJ0 CITY/ZIP WELL C ! -7U Q� 5 110 CROSS STREET V APN 1 C7O PARCEL SIZE • NEAREST -r— Aj ft 60 OWNER NAMECOaKt L ft PHONE60-T-76 OWNER ADDRESS 364-7 a-itor&CITY/STATE/ZIP NEAREST WELL SUMPS WIDTH CONTRACTOR A - Po/ - PHONE - 00 \ t' ��y � L � ��/�Ic CONTRACTOR ADDRESS --F[_ W CITY/STATE/ZIP CJ(JYJJ LICENSE ;( C-42 l C-36 OTHER A NUMBER W V V� EXPIRATION DATE `t 17 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 17 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLAT �REPAIR/ADDITION ENGINEER DES NED/ALTE NATIVE / W REPLACEMENT C, OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 'A RESIDENCE 1-1 COMMERCIAL CJ OTHER NUMBER OF LIVING UNITS: 2- NUMBER OF BEDROOMS: Z NUMBER OF EMPLOYEES: 19 SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP LEACH LINES LEACHING CHAMBERS ft PROPERTY LINE ft DISTANCE TO NEAREST WELL ft FILTER BED WIDTH A ft PROPERTY LINA ft LENGTH ft DISTANCE TO NEAREST WELL Aj ft MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ SEEPAGE PITS NUMBER WIDTH _ DISTANCE TO NEAREST WELL CAPACITY Itl" _ CAPACITY ft FOUNDATION ❑ PKG TX PLANT # OF LINES ft FOUNDATION ft FOUNDATION ft FOUNDATION ft FOUNDATION ft FOUNDATION ft FOUNDATION gal # OF COMPARTMENTS_ - gal # OF COMPARTMENTS�✓�y ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LENGTH OF LINES ft ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft ft DEPTH ft A ft PROPERTY LINA ft ft DEPTH ft ft PROPERTY LINE ft ft DEPTH Ur T n _ Aj ft _ft PROPaWLINE V -) 2018 ft ft DEPTH PAn9ft /el _ ft ft PRO NMEIu, . NTY ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE *rTH 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 WORKE SIGNED Application Accepted B Final Inspection Byj� Character of Soil toK COMMENTS n DEPARTMENT USEIONLY Date to Area Employee ID# Date /0 I' 't- ❑ SPECIAL PERMIT - Approved by 3 t: Pit/Sump Soil CharacteS: PE Code SC INFO Received B heck# ash Amount Remitted Date Permit/ Service Re uest # Invoice # Permit ID# Z b D 2 0 ►o —I (;0 -1112-- 42-01 5/5/17 3354 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT T,