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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 a 1, -- CALL 209 9537697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS S� 1� 51rOA (G 90.)1C IN 0\ CITY/ZIP f-\CA -3 , V / CROSS STREET 1i�ICZv APN_QpS-1 V O IC PARCEL SIZE / (-7-'4- > p OWNER NAME �L 0 1 0 PHONE �� /o 6 OWNER ADDRESS9 tc f% S �9 CITY/STATE/ZIP ^Y CONTRACTOR VQCi`J 1 CO'NSA/ `SOC<t •Vt' k N ` PHONE ,v CONTRACTOR ADDRESS R _CITY/STATE/ZIP L�� v'J `/J �p LICENSE I I C-42 I I' C-36 OTHER R NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1_I PERC TEST # BUILDING PERMIT#_ _ AND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIRAADbjMCIW 77 1 ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: WWI 5r SEPTIC TANK TYPE/MFG �L" CAPACITY Sy� gal #OF COMPARTMENTS Z l ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS cam,, Ih DISTANCE TO NEAREST: WELL i 7J ft FOUNDATION S+ ft PROPERTY LINE �, ft ccll ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) J .� ❑ LEACH LINES LEACHING CHAMBERS N #OF LINES Z LENGTH OF LINES '3ti ft DISTANCE TO NEAREST WELL�� ft FOUNDATION 0 ft PROPERTY LINE S , ft tv ❑ FILTER BED WIDTH ft LENGTH __ ft DEPTH ft l� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 7 ❑ 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 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ftS FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER 1 WIDTH y O+, ft DEPTH 21;; r C ft DISTANCE TO NEAREST WELL ft FOUNDATION I ft PROPERTY LINE 5 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 COMPENS ON LAWS. MINIMUMHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE T3->5 w _�r`� "'� DATEIf e Cto A T E EPA R TMEN TLYSZ QFNL Y Application Accepted By Datef 1 Area Employee ID#VA dAAR Final Inspection By CI SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE Sc Received Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Re uest# 6 2�� 650. 1 Gl-I �°I SL 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17