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40 . ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN„'OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR F OM DATE ISSUED <br /> JOB ADDRESSSTM 9 L-AV1( CITY21P O <br /> � <br /> 0,-.;,T <br /> CROSS STREET ✓f n[L (SAA QD APN�l_ 3 C��I-J+ 130 PARCEL SIZE 5-00 > <br /> OWNER NAMEP , JW 1) �r j(V&�jW/'�l (G' PHO/NE� T� q'1 <br /> OWNER ADDRESS 67�� V PV O 1�i �()Cj V� `5� <br /> f�A 9C CIT!/STATE/ZIP <br /> nL <br /> CONTRACTOR� id A' S6 1� '1 �/ KJCPHONE �A <br /> 9667 <br /> CONTRACTOR ADDRESS 4-000 kV - V�+� 4C /OQ � CITY/STATE/ZIPSincimn, C" <br /> LICENSE V C-42 ❑ C-36 OTHER NUMBER loot r EXPIRATION DATE 4,11 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X G <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER D E / LTERNATIIVVE .l <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTIC 2018 7 <br /> INSTALLATION WILL SERVE: 11Q RESIDENCE ❑ COMMERCI L ❑ OTHER SAN JOanI ,.,,...-_ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF QNME�T� <br /> 16 SEPTIC TANK TYPE/MFG CAPACITY 12nn gal #OF COMPARTMENTS YVNT <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION , ft PROPERTY LINE 50 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> rd LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE V} ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST n WELL ft FOUNDATION ft PROPERTY LINE ft <br /> V SUMPS WIDTH 2 TR— ��r4- DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATIONft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH 2?6 t ft DEPTH ?� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION I+ ft PROPERTY LINE • ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN ,TION LAWS. <br /> I SHO A / QU/RED FOR I C ON - ASE CALL 209 953-7697 <br /> SIGNED TITLE DATE it <br /> 01N <br /> 7 <br /> p P <br /> c <br /> DEPARTMENT SE ONLY <br /> Applicatlon Accept ad ByDate 1 Z Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Deptl of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 0k= to ��jT no �Pf- <br /> b <br /> " o ki -'- W J R DRAS' ?-r,2 <br /> PE SC Received ec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B k1Cash Remitted Service Request# <br /> 42f0 .� ►Ly IG-145 0p�q°I-1 <br /> 42-01 00 G(i2S Wy�d c W0'" I Y/ ` ` Y4 ONSITE WASTE` ER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />