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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN�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.FFRyOM DATE ISSUED JOB ADDRESS u � Q Zh go CITY/ZIP S:jb JC br) /cA !id I ,1 CROSS STREETIre to A'f 61 ji Z, APN a► I� l PARCEL SIZE L v OWNER NAME (Q b(?��, 1„ rz+ f�!N^o _ r PHONE OWNER ADDRESS i!71 111Q e y(i�A w y Aft 71 l� _CITY/STATE/ZIP {.�;�.��'A 17r3 CONTRACTOR + IS �:Jl�L�C <SKr _____ PHONE 5;4<6 .) CONTRACTOR ADDRESS �[� (t/sl7 CITY/STATE/ZIP Y� L�'/E 713 LICENSE F1 C-42 ❑ C-36 OTHER NUMBER 1 EXPIRATION DATE WATER TABLE DEPTH. ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT#p AND USE APPLICATION# TYPE OF WORK: i'. NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT 1 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: W RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: i NUMBER OF BEDROOMS: .3 NUMBER OF EMPLOYEES: 9/1'SEPTIC TANK TYPE/MFG 04 1. CAPACITY nL Hei.6 gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY _ gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL 110 ft FOUNDATION It PROPERTY LINE It ❑ LIFT STATION SIZE _TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) U"LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES 7�r It DISTANCE TO NEAREST WELL ft FOUNDATION_ I r� ft PROPERTY LINE �r q j f It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE__ ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH .__ It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft Ul SEEPAGE PITS NUMBER WIDTH �,.} _ It DEPTH I It ..�_ _ _ DISTANCE TO NEAREST WELL ;/ FOUNDATION - ib, ft PROPERTY LINE lI 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. MINIMUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED __ TITLE�n Etc—'(–a f— DATE r� O "I& L E P •t - DEPA RTMENTIUSE ONLY Application Accepted DateArea; Q Employee ID#E:-� l_ro Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/SUmp Soil Character: _. COMMENTS 0190c- INwr(c svr-r5144AJn wjSA I_ raU L— S - t5 0 f / J 441 1- 0J1� PE SC ReceivedChec Amount Date Permit/ Invoice# Permit ID# Code INFO RAi Remitted Service Request# 23 30 1 S° 8 5 • �. -. 42-01 J ✓I' ] �u' /� w'`�" V'�"-" �qONSITEWAS ERTRTMNT SYSTEMPERMIT 5/5/17 /