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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 CITY/ZIP S Lk r I CROSS STREET �l�A04W;&Z �� APN 1�/ /V 0 -' 2110 PARCEL JSIZE o OWNER NAME �4��, ,,4 C� > 10001 OWNER _ PHONE,�J ,�7 OWNER ADDRESS `Y�'I I 1�� CITY/STATE/ZIP 4mC cq( CONTRACTOR ' l' PHONE � CONTRACTOR ADDRESS -/ 9T IsJZJ -7-4<-7-4< CITY/STATE/ZIP � � LICENSE L C-42 El C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: oordin tes X Y °Wi Ll PERC TEST # BUILDING PERMIT# AND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION EPAIR/ADDITION ENGINEER DESIGN156a/�LTR ATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM LL DESTRUCTION d�JJ_110 INSTALLATION WILL SERVE: RESIDENCE U COMMERCIAL ElOTHER SANJOAQ(jl ,f.,411— El _ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPL YIRONM N SEPTIC TANK TYPE/MFG _ CAPACITY Z"4l?- gal #OF COMPARTMENTS TMENT ❑ 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) ................. LEACH LINES C LEACHING CHAMBERS #OF LINES LENGTH OF LINES o J ft DISTANCE TO NEAREST WELL ft FOUNDATION �/>>f/- ft PROPERTY LINE�S ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft ❑ 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 ft f/f0Uf�TION ft PROPERTY LI� ft SEEPAGE PITS NUMBER WIDTH 7a // ft DEPTH Z 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 COMPENSATION LAWS. MINIMICAM124 HQURAGINNeE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE_,�� DATE %�-;z— INI 6 EPARTMENT USE N Application Accepted By IRA Jj Date Area Employee ID# Final Inspection By �' __ Date 3/ 19 11 SPEC AL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS GLvt U 0. oyl s . 3 �- PE SC Receivedec Amount Permit/ Code INFO a ash Remitted Date Service Request# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17