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/ ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P 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 � �� t►Jn 1-3 J. L/�`N C: ��+�h CITY/ZIPL-) - CROSS STREET �,A��y�/ (A~ + ' APN L GS O PARCEL SIZE tv OWNER NAME �A� t A�� rtJ PHONE ��, LL� m OWNER ADDRESS Q �A� � CITY/STATE/ZIP VV CONTRACTOR ESTLo�� `�'�t-9 oC C . ilj L PHONE J 1 4 S y CONTRACTOR ADDRESS J� �� t I 7 r(L 3 CITY/STATE/ZIP L'3 o)T ` f 0 LICENSE 3 C-42 _I !C-36 OTHER NUMBER l/G I t S_7 EXPIRATION DATE WATER TABLE DEPTH: 1�9 6 ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION A REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT �.'•\1� OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: L I RESIDENCE J COMMERCIAL I I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: Lj SEPTIC TANK TYPE/MFG ` CAPACITY Z J J gal #OF COMPARTMENTS Z 1' ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 1 / 9 DISTANCE TO NEAREST: WELL ft FOUNDATION t ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) i I LEACH LINES Ci LEACHING CHAMBERS #OF LINES �_ LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft V' ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI i� It J ❑ SUMPS WIDTH ft LENGTH ft DEPTH i� jV;'n It 4 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LYII ftLIDISPOSAL PONDS WIDTH ft LENGTH ft DEPTH /'1 20m ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPE IdDAni uk, ft SEEPAGE PITS NUMBER ` WIDTH f/bft DEPTH?iS►��E�NVIRON NN ft DISTANCE TO NEAREST WELL_1_0� ft FOUNDATION ft PROPERTY LINE'UEPARM&r 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))9353-7697 SIGNED TITLE �i �-�I �� DATE WWI 4�1 I I EPA RTMENT USE O LY Application Accepted BL Date Area Employee ID# w ) Final Inspection By Date PECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: VSu oil C ar ct er: V COMMENTS ` I PE Sc Received Chec Amount ate Permit/ Invoice# Permit ID# Code INFO B ash Remitted DService Request# �a -11-i� gt2 J� 42-01 OK- �n C,(-s 1 t' t� u~JC- r / �ONSITE RTMNT SYSTEM PERM 5/5/17 /,,11,�t�ii�� 7 mo a Gvv fel -ee� `— t,7 7''r' ./ i