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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PER��M/IT /� L CALL y2�09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ly JOB ADDRESS �O f�-��Y� e SS '� CITY/ZIP /�GyJrn�a - ��SO ,�� CROSS STREET yI� C[� f-1ZC�M�STLJ7JC�G ICcJIC_ APN E/lJs7'fYv�VV PARCEL SIZE/ `� o OWNER NAME 1D LiJGtA �n/S N O I�-ZG PHONE.�7--2 O J A rn OWNER ADDRESS/(1: "a /IA �/ t/V G ��- _ CITY/STATE/ZIP CONTRACTOR C.GII /�` k0,966e & PHONE 3I.,9,-/�z7 JJIF CONTRACTOR ADDRESS ��/- 'ellx—`J1_�i� _CITY/STATE/ZIP L LICENSE ❑pL-02 ❑1C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y Ll PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDrnON i ENGINEER TIVE ❑ REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM U DESTRUCT INSTALLATION WILL SERVE: PLRESIDENCE ❑ COMMERCIA ❑ OTHER NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EM@EfFE El SEPTIC TANK TYPE/MFG ��1/5�`!t�*�S CAPACITY gal #OIS,&15IrNT6 TY El GREASETRAP TYPE/MFG CAPACITY gal #OA ��AI�IIiffI ITAO DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTYFLINEPARTMENT ft ❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) i LEACH LINES LEACHING CHAMBERS #OF LINES�_ LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION AW' It PROPERTY LINE 7iJ' ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft PL SEEPAGE PITS NUMBER :3 WIDTH ` / ft DEPTH rf � ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE So 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 77-SIGNED -� TITLE G�1 DATE 10 PARTMENT VSEjO1UjLY /ten Application Accepted y Datej2-/1 0 f' Area tY a _ Employee ID#� Final Inspection By to El SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PIVSump Soil Character: COMMENTS '��, f D6J � PE SC Received Chec / Amount Date Permit/ Invoice# Permit ID# Code INFO ys Remitted Service Re uest# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17