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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NctN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP I,�' CROSS STREET a�IT� 1 A APN PARCEL SIZE ,Z/a A�012J;� y O 0 OWNER NAME A 1-1 /�� PHONE OWNER ADDRESS ZZZ I D�fMt.y�s CP /NY/ _CITY/STATE//ZIP �} �7 C 117 CONTRACTOR PHONE / 20`7 ` V l 0- L 3 CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I I C-42 1 I C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: / D J ft GEOGRAPHICAL INFORMATION: COO dinateS X Y LI PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLREPAIR/ADDI I N ENGINEER DESIGNED/ALTERNATIVE REPLACEMENATI OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL 11 OTHER UMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG 17 L..' CAPACITY 2W L 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) . .............. ........ __.._. -------__._.__ _.__-. --_.-.____r ..__.._...._- _. l� LEACH LINES LEACHING CHAMBERS #OF LINES L LENGTH OF LINES 100 ft I ` DISTANCE TO NEAREST WELL It FOUNDATION U T ft PROPERTY LINE f ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft %, DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft r ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 COMPEN ION LAWS. WKWUMMaud ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED - TITLE DATE uiv SAM jEV-1R'wn1KIAA1 :WA-t— �TH D Pq r EPARTME Ot T JfSE LY Application Accepted By Date Area "I Employee ID# Final inspection By__ ` _ __ Date W _ 1-1SPECIALPERMIT-Approved by .kL Character of Soil to Dept of 3 Ft: PiUSump Soil Char ter: COMMENTS araP -k,51 Adu lli'lpr--tiko lInswetvii PE SC Received Check#J Amount Permit/Code INFO B -Cash-') Remitted Date Service Request# Invoice# Permit ID# 1 ly 1.�' 5R0Q-7x927_- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17