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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-REFUNDABLEPERMITCALL 209�j953-7697FOR INSPECTIONS EXPIRES'1/YEAR FROM DATE ISSUED JOB ADDRESS (r1� 7,Jlgr4Vd✓- -- - CITY/ZIP �v CROSS STREET UJI`S APN`,/I-9-05�0 PARCEL SIZE Y v OWNER NAME f O /W _ PHONE 7-42' 3�osa m OWNER ADDRESS G q�� J CITY/STATE/ZIP CONTRACTOR .e'419171' !//'//C[1 G �y PHONE �L %_5OZ7 CONTRACTOR ADDRESS l3�Sc/+�� I� __ CITY/STATE/ZIP GYd- J LICENSE [1$_42 LTC-36 OTHER NUMBER 7 S�Oy5— EXPIRATION DATE WATER TABLE DEPTH: ( It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION Dt REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: J NUMBER OF BEDROOMS: LjNUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG /Sh w,j _ CAPACITY gal #OF COMPARTMENTS Z _ ❑ GREASE TRAP TYPE/MFG _--- CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 151, LEACH LINES ❑ LEACHING CHAMBERS #OF LINES_ LENGTH OF LINES j60 It DISTANCE TO NEAREST WELL Z0 )IL- ft FOUNDATION kd ft PROPERTY LINE /O It ❑ FILTER BED WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It Fd- SUMPS WIDTH � _ . _ ft LENGTH /�/ ft DEPTH_ /y It DISTANCE TO NEAREST WELL —700 Dl' It FOUNDATION IQ9? It PROPERTY LINE Jt1 ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL _ ft FOUNDATION It PROPERTY LINE It ❑ SEEPAGE PITS NUMBER _ WIDTH_ ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It 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. MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED — TITLE DATE / Z C Nr MAI JA Ep 019 I COUNTY T ) AL ENT bEPARTMENIT USE ONLY Application Accepted y Date Area Employee ID#� Final Inspection By Date_ F1 SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: it/Sump Soil Character: COMMENTS-T1'G�L!- PE SC Received a Amount Permit/Code INFO B ash Remitted Date Servi a Re uest# Invoice# Permit ID# Zg l 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17