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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SANVOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186E E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 .NON-REFUNDABLE P1E,RcMIT{j� CALL 209 953-7697 FOR INSPECTIONS EXPIR E S 1 YEAR FROM DATE ISSUED JOB ADDRESS t_� '1 'J,�W�Q S�n((�_. CITY/ZIP CA ROSS STREET I� -/V G ( / APN _O - AP/ARR�CEL S/IIZE Q > OWNERNAME I I LOYifAlfFI 6"4(-LE" — PHON��L.V'�) rf�S ��`'� OWNER ADDRESS 4N-?> Q-60 c,—L t`d � CITY/STATE/ZIP ��lilr NAL / TT CONTRACTOR r " !N�C PHONEI _ CONTRACTOR ADDRESS �'�e2ax «S:�— CITY/STATE/ZIP r LICENSE 11'7C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOT inates X_-_ - Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I I REPAIR/ADDITION ENGINEER DESIG ED/ALTERNAT E REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION , I If INSTALLATION WILL SERVE: ` RESIDENCE ❑ COMMERCIAL �j [_l OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ✓ NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG _CC"_ CAPACITY �f il�lJ gal #OF COMPARTMENTS GREASE TRAP TYPE/MFG __ _ _ CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL I n0I-f- ft FOUNDATION _ ft PROPERTY LINE _.ft ❑ LIFT STATION SIZE TYPE OF PUMP--- _ _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES I_ LEACHING CHAMBERS _ t #OF LINES LENGTH OF LINES_ � ft DISTANCE To NEAREST WELL �_ ft FOUNDATIONft PROPERTY LINE ft ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE 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 it DEPTH ft DISTANCETO NE LST WELL It FOUNDATION ft PROPERTY LINE ft /� SEEPAGE PITS NUMBER __ WIDTH � DEPTH ft DISTANCE TO NEARES I WELL ft FOUNDATION &2 f 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. MIMMUM 24 HOUR 4jjj4NMN0T10E REQUIRED FOR INSPECTIONS-PLEASE CALL 209 9,53-27697 SIGNED TITLE DATE T U ry, T EPARTMEN US O LY 414— Application Accepted By Date Area Employee ID# 0 Final Inspection By Date7 ❑ SPECIAL PE MIT-Approved by Lj�4A Character of Soil to Depth of 3 Ft: Pit/Sump Soil Charact ;,.�_a__ ¢ % COMMENTS _I! z SSG G1T1 Old i o,-,, &S,Lias S. 6 l u," by qu&90 G� PE SC Received Che ount Date Permit/ Invoice# Permit ID# Code INFO ash Remitte Service Request# siz 42-01 ^ ^� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5!5/17