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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 ,N-REFUND.;,BLE PERMIT �� CALL(20p)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB AD`IJRESS 5o3 'Peau ��lL/ CITY/ZIP O CRG,;S STREET 'le//,// el- /`��7I ____ __ APN 750 _PARCEL IZE p OWNER NAME TIM wr<�`� ��p�7J�laLiA- _ - /�PHONE OWNER ADDRESS e I '/ II c' CITY/STATE/ZIP _gA20-12 CONTRACTOR (�C�pg1 V dif XiI�L _ PHONE CONTRACTOR ADDRESS 931 4e Qr SOH - CITY/STATE/ZIP _6,dol/j LICENSE ❑jjfE-42 ❑GC-36 OTHER NUMBER EXPIRATION EXPIRATION DATE /� 1 WATER TABLE DEPTH:_ _ fl GEOGRAPHICAL INFORMATION: Coordinates X_ -_ - _ Y PERC TEST # ( BUILDING PERMIT# � LAND USE APPLICATION# TYPE OF WORK: ' NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT 11 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION _ INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL h 0-1-HER -_ NUMBER OF LIVING UNITS: -.___ NUMBE/R OF BEDROOMS: a NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG �OKf�e ✓ CAPACITY 1QL0I0 gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _. _ CAPACITY gal #OF COMPARTMENTS j / / DISTANCE TO NEAREST: WELL 11 ft FOUNDATION ft PROPERTY LINE 8d ft ❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS #OF LINES c;t LENGTH OF LINES 54 ft / x DISTANCE TO NEAREST WELL -/00 ft FOUNDATION25-i_ft PROPERTY LINE S ft ❑ FILTER BED WIDTH ft LENGTH ft 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 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 4 ft PROPERTY LINE ft xSEEPAGE PITS NUMBER WIDTH ft DEPTH ��♦ ft ( ` DISTANCE TO NEAREST WELL �SQ ♦ ft FOUNDATION `� ♦ ft PROPERTY LINE /O 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 CONTRACTOW; STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 SIGNED TITLE _ DATE 4 25--Pi 9 JOOO i �� EPARTh1EN ISE NLY G Application Accepte _. Date C Area �% Employee ID#__ Final Inspection By ' Date _ SPECIAL P[[[ERMIT -Approved by Character of Soil to epth of 3 Ft: _ _ iUSump Soil Character: Character of Soil to�epth COMMENTS � _�_ D_ '4 � ? PE Sc Received heck#/ Amount Permit/ Code INFO BY . flemilted, Date Service Request# Invoice# RMEIVED Z� 0XYZ, Ll --- SAN JOAQUIN COUNTY 42-01 ONSITE WASTEWATER TRTIvENVhRGNMENTft 5/5/17 HEALTH DEPARTMENT