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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 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 t 4 qC-0f(y A L Cyl /ZIP LJ7 1L `A 152� CROSS STREET _ C IAA% to -T APN I 56 �l PARCEL SIZE O t _6 t d OWNER NAME ��N L rj Inti) fr> f O PHONE 'SZ� 3af 1 OWNER ADDRESS W f<<' NJ CITY/STATE/ZIP �p (-M � CONTRACTOR WGS 1I �A�( -7 1:1NQ4 IAI)LI IIJ `' PHONE �J� - )39. 130)-t CONTRACTOR ADDRESS J1� + 1 ,yA- o I, CITY/STATE/ZIP La C-R °'►;L`ra LICENSE C-42 C-36 OTHER / / �M R EXPIRATION DATE lz�u_� 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 REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: I RESIDENCE I COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: lx SEPTIC TANK TYPE/MFG i e� L CAPACITY ("Zgal #OF COMPARTMENTS—Z ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS �� DISTANCE TO NEAREST: WELL '�-7�t ft FOUNDATION ft PROPERTY LINE C, ft ❑ LIFT STATION SIZE TYPE OF PUMP_ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES X LEACHING CHAMBERS i N ct I tr K7.a #OF LINES d- LENGTH OF LINES �� ft DISTANCE TO NEAREST WELL r'6"7' �Ot ft FOUNDATION I3 ft PROPERTY LINE t , �,� 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 4±' ft LENGTH (2-' ft DEPTH ft DISTANCE TO NEAREST WELL AY 01'fi ft FOUNDATION �)'P ft PROPERTY LINE S I f ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LITE4WITH ft P—"E"ZF PITS_ NUMBERft DISTANCE TO NEAREST I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCJOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLEDATE C.� Or- i• A E M1 s ARTMENT USE ONLY Application Accepted By/ c Date I - )26 1?Area 4 Employee ID# U( h(1C Final Inspection By_ 4 Date 6 ,CG 0 SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ,A,wj w2 0 0 I PE SC Received Chec Amount Permit/ Od Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# M't l L r2 3 0 l°I �2 6G 1`� nl 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 tj