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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)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP &1O1C/rC1rY;A'aD. Cr, 9sa 3 CROSS STREET c �kT1Q1� APN �2�E 7"s-6 � � PARCEL SIZE hatp OWNER NAME_ �� r�.E� � PHONE p-70 .7- C I-6z 2 OWNER ADDRESS �/�� /� O�� CITY/STATE/ZIP CONTRACTOR- CS 11Srx��D[� PHONEr� 3 / p CONTRACTOR ADDRESS 3 3 /J9AX FVFG L CITY/STATE/ZIP ��/ G/� /�� L/ \ aa LICENSE I C-42 I I C-36 OTHER NUMBER& //-5rEXPIRATION DATE 0?0 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE 1C REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER O NUMBER OF LIVING UNITS: f� NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: 11 SEPTIC TANK TYPE/MFG + Z_ CAPACITY 1-4 60 gal #OF COMPARTMENTS ❑ 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 �✓ LEACHING CHAMBERS,;"'/ 4 67"tof< #OF LINES 3 LENGTH OF LINES S�S� ft Q DISTANCE TO NEAREST WELL /00 ft FOUNDATION 5:0-'f' ft PROPERTY LINE sd } ft ❑ FILTER BED WIDTH ft LENGTH It 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 LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL A ft FOUNDATION ft PROPERTYLINEft SEEPAGE PITS NUMBER '!> WIDTH 4w% ft DEPTH 9 + ft , DISTANCE To NEAREST WELL 15 ft FOUNDATION 10-1 ft PROPERTY LINE �7'�I- 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 COMPENS iTION LAWS. MI UM £'HOWWADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED s. TITLE DATE I FFFT FR I I I I I T I I I I I I I I 1 DEPARTMENTUSE NLY Application Accepted By Date �7 / Area Employee ID# � Final Inspection By Date / �Z 11 SPECI PE MIT-Approved by PAYMENTCharacter of Soil to e h of 3 t: Pit/Sump Soil Character: KEECEIVED COMMENTS I�Iv i i-2019 IiAN JOAQUIN UNITY PE SC Received Check#/ Amount Permit/ ��y��NME TAL Code INFO B Cash Remitted Date Service Re uest# Invoice# �AC`tN'�3EPAR MENT 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17