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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN 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 ADDRESS IS Lj i1ovh es`4 CITY21P 1(` (- �✓ v CROSS STREET Kass n RO APN 4-7 �� V PARCEL SIZE ( � p c OWNER NAME /V GL �(J --- PHONE f OWNER ADDRESS 13!01 qj2-rH /1 v c CITY/STATE/ZIP �' � 1 CONTRACTOR 1 re Grp (�{� ��J C�/ _ PHONE CONTRACTOR ADDRESS I ) &-)k IOSC� _ CITY/STATE/ZIP Y/ I��J/z` �` ) ✓"J �� LICENSE , I C-42 1 1 C-36 OTHER�� NUMBER- I __EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y I I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE 0 COMMERCIAL E OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: Rl SEPTIC TANK TYPE/MFG P itL CAPACITY 1660 gal #OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL (00T ft FOUNDATION 4 ft PROPERTY LINE 10 0, ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) -....... __ __ _.._...._.._. P"LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES 14 n ' ft DISTANCE TO NEAREST WELL I W 7" ft FOUNDATION GOI ft PROPERTY LINE �� I 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 RAYMEoP��. ft 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 LINE0 ft El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH �UIQ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LttPU"��ee��fJOAQUIN CO NT-Yft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH NVIRONMENTAL ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ENT 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 24 H01JR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE 7� `�7�Jt- DATE O 1 f Y Ili EPARTMENT jgSfjO1VLYp��/,}� Application Accepted ByDate 3 Area Employee ID#� -``-� Final Inspection By Date / w l l L K I-1 SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PiVSump Soil Character: COMMENTS PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO ash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17