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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT r AN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '1868 E.HA7_ELTOPi AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDAB PERMITCALL 209 953-R97 FOR INSPECTION EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS RAW �` �5(L-, _ CITY/ZIP CROSS STREET —J G"� OF �{��+ V�W APN ^O O PARCEL SIZE 55,2 1 d OWNER NAME� JIFM�f TIF�Qs� Tj PHON14 1 LO4— OWNER ADDRESS CITY/STATE/ZIP q5 CONTRACTOR AIPI v J 1�+�/ PHONE � M CONTRACTOR ADDRESS 4wnm+ Wsuj 'ICITY/STATE/ZIP LICENSE )(EC-42 LL C-36 OTHER NUMBER EXPIRATION DATE t 11 • l WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION TAt-- ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 1)( RESIDENCE F1 COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I �.{.� �,�� NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG IWDL 111 Amc l_+ IM`5M CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL I� ft FOUNDATION ft PROPERTY LINE 15+ ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES 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 ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEAE A� ft 13 SUMPS WIDTH ft LENGTH ft DEPTH C ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINYA ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH Ily ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY. 140ICU& ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH NFA(rONq,4 COUAI, ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEA 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. ��fhr O NQ TICE REQUIRED FOR"112MONSfi PLEASE CALL 209^^ 53- 97 SIGNE TITLE DATE Y t V. '► � r ,rte' 1'r9 .,.�M� ,r '^. .1,. R.- 1 • D PARTMEN USE LV Application Accepte y Date I Area Employee ID#� Final Inspection By Date F1 SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 PIVSump Soil Character: COMMENTS PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO B ash Remitted Service Request# OD S def 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17