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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN,J5AOUIN CJUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> 'A/ q/� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _I I YtL q 17 FROAl1-,4(.j xD --CITY/ZIP LO 'Z 9�Z go <br /> B <br /> � m <br /> CROSS STREET D EA2 L Kjt (< Kt7 APN 0 & PARCEL SIZE <br /> v <br /> 0 <br /> a <br /> OWNER NAME E-1>01'6' KE LLF-2 PHONE y <br /> OWNER ADDRESS Sr�/�'IE CITY/STAT IP �7 <br /> CONTRACTORS CO,j"7- ue7xzs.✓ `-' E7 T j"C, T,(- PHONE 7 G �� <br /> CONTRACTOR <br /> �ADDRESS i�0.. t`3ox 7 L y CITY/STATE/ZIP E9 !;,z0 ��A /�S75: <br /> LICENSE 11/ 42 C-36 OTHER NUMBER 22Ito EXPIRATION DATE 15 c a-z D <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL LI OTHER <br /> NUMBER OF LIVING UNITS: 11 NUMBER OF BEDROOMS: if NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG ?j1- co✓UZ-12t'«- CAPACITY 400 gal #OF COMPARTMENTS 2 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 10'21 ft FOUNDATION 20+ ft PROPERTY LINE 3�� ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES l- LEACHING CHAMBERSS''f #OF LINES 3 LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL iWf ft FOUNDATION S' ft PROPERTY LINE d/F ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH �_T 1 <br /> VMEN ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH V ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY 2018 ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTgAW80AQVIN C ft <br /> mourAl <br /> ElDISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ENVIR €PARTMENT ft <br /> DISTANCE TO NEAREST WELL ft /FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH 3rh ft DEPTH 2S� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION /0' ft PROPERTY LINE SCJ ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSSkTTION LAWS. <br /> MINIMUM a'WHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE i7(tbfjt,-,t DATE 10- 23 - IS <br /> GII <br /> o <br /> NO <br /> O <br /> �. DEPARTMENT U E ONLY <br /> Application Accepted By If Date Area , Employee ID# �u <br /> Final Inspection By Date l D/7_ ElSPEC AL PERMIT-Approved by <br /> Character of Soil to Ekpth Uf i F Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Recei edheck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service Request# <br /> X0---L <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />