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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 'I 953-7697 FOR INSPECTIONS EXPIRES YEAR FROM DATE ISSUED ^" JOB ADDRESS I �,Cl P4 ' ✓C.y�r�5 K/� ( CITY21P L-( Z CROSS STREET N-• -Tkc)ch+v^ KA- APN_40 e6 PARCEL SIZE144 �� p OWNER NAME by.,A L—Po-,jr—!1 PHONE OWNER ADDRESS 117 �,�� I - rr C'A „x- CITY/STATE/ZIP I &R �� 1,N2- CONTRACTOR :YS �p°i�C�' '� 1t 7 �`H 6 PHONE �I I L-Ci-7 9- 2N S 5- CONTRACTOR ADDRESS �D Mqy-1 S G Vl `'re4.rk— Dr CITY/STATE21P !�&I'rZlt"llY.b �'� 1758-2-q LICENSE L�K6-42 11 IC-36 OTHER NUMBER -1 ZZLt`21 1w EXPIRATION DATE WATER TABLE DEPTH: �`�ft GEOGRAPHICAL INFORMATION: Coordinates X Y LI PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ltll--RESIDENCE Ll COMMERCIAL I I OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 2- NUMBER OF EMPLOYEES: U SEPTIC TANK TYPE/MFG 7 L CAPACITY �Z�� gal #OF COMPARTMENTS -2— U ❑ 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 I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPER(T)Y LINE ft FILTER BED WIDTH 2-3 ft LENGTH ft DEPTH � D�) ft DISTANCE TO NEAREST WELL )QC'`+- ft FOUNDATION IL �� ft PROPERTY LINE r 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 FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 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. MINI UR ADV-AJVCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE Cog. P ti'., G jet DATE `1 Z. )el r• 1 11 11 lit 19 A U Lr cftEAg M T � EPARTMENT SE NLY Application Accepted Date Area Employee ID#� Final Inspection By Date 2, q LI SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft. Pit/Sump Soil Character: COMMENT Q 4,0 �' l'• i-T l 2 3 n PE SC Received Check#/ Amount Permit/Code INFO B Cash. emitted Date Service Request# Invoice# Permit ID# r 1� 7 42-01 / / ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17