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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 NQN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS l6T al1s�O CITY/ZIP 4 CROSS STREET S APN ;�O!j '31 0 I y PARCEL SIZE � OWNER NAME o ro C_45, W `qe PHONET�r�7l!!� OWNER ADDRESS j CITY/STATE/ZIP r CONTRACTORy r\ 111�� 1gc1c `` S T✓'z-� PHONE W� L d �` CONTRACTOR ADDRESS I0V Isbe 6_z j CITY/STATE/ZIP /r , '1" '� Imo- `s3_3(1, LICENSE 1 1 C-42 FI-C-36 OTHER (� NUMBER &`�iSSL4 EXPIRATION DATE l�. WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# I O Oq A. LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: p NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: Q/SEPTIC TANK TYPE/MFG 164-L _ CAPACITY 0 b a gal #OF COMPARTMENTS 'P- ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE To NEAREST: WELL I bO4- ft FOUNDATION �' ft PROPERTY LINE IVU'p ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ---- LEACH LINES LEACHING CHAMBERS #OF LINES 3 LENGTH OF LINES ( ft DISTANCE TO NEAREST WELL I to ft FOUNDATION IO, ft PROPERTY LINE I C)I 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 ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH Q f J DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE - �AV ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 04� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE , Tt I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT AN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICE SE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE_ C"011.1'-rc` -dr DATE �] I 49 l/ EPA RTMENT JJSE QN1 Y Application Accepted By t 444nr Date 67 0 ldV Area Employee ID# Final Inspection By Date 2Ax ❑ SPE IAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Check Amount Date Permit/ Invoice# Permit ID# Code INFO ash Remitted Service Request# ZI I S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17