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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT TSAN 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 f'1�t►JA i. L�°`~C: ��' CITY/ZIP TJ ti 7. tj A /�C� tyn CROSS STREET G��V4 �~ + `J APN o:) O C PARCEL SIZE L 7Y tv p OWNER NAME �'�� t S^1 A A f O PHONE y l I - y Zt OWNER ADDRESS A. CITY/STATE/ZIP CONTRACTOR WESTcof-5`l i—SA04"0C II� L PHONE -T t a -FA CONTRACTOR ADDRESS yl W�t 1 r CIL 3 CITY/STATE/ZIP LICENSE I C-42 I i C-36 OTHER NUMBER B G(`J / EXPIRATION DATE zo Z-'*:) v WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION 1� REPAIR/ADDITION ENGINEER DESIGNED/ALTER TIVE REPLACEMENT Ta"A\ I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: I I RESIDENCE L COMMERCIAL I I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG 1 �L. CAPACITY Z J� gal #OF COMPARTMENTS Z ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS IN I DISTANCE TO NEAREST: WELL �v It FOUNDATION 1 J ft PROPERTY LINE ZJ ft ) ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) i r LEACH LINES I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft - DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft r ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIQflqE1V ft J L3 SUMPS WIDTH ft LENGTH ft DEPTH �'(etteIVE.n) ft 4' DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY Llpl ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH �1 2014 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPEft SEEPAGE PITS NUMBER ` WIDTH h ft DEPTH 'NV1R0N Ey-r-Nay ft DISTANCE TO NEAREST WELL [b ft FOUNDATION ft PROPERTY LINE EFARTMENT 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209))953-7697 4 SIGNED TITLE lir �-� �� DATE -17 I I I ° �• � ./ ri S�01 PE SC Received Chec Amount Permit/Code INFO B ash Remitted Date Service Re uest# Invoice# Permit ID# MMOL401 Q2 y �� 42-01 �-ro ) Po T 1 ty �~� ��'y ONSITE TRTMNT SYSTEM PERM 5/5/17 rnw-L- r"m-l7 M 7�-� 7, . c /V t /pr,