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ONSITE WASTEWATER 111,I A` !II,)lENT SYSTEM PERMIT QV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT L CALL 209 95L3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMDATE ISSUED JOB ADDRESS 68kp-// / � aAn+tx �cI a. Cowl T CITY/ZIP t� S CwkLyi CROSS STREET �LG�- C&SCVV, na C owe+ APN 1 V 7 q o062- PARCEL SIZE p OWNER NAME LoIC �1 SLC \OG44 ��tS�� PHONE 2-09 14 193' ;3 71 v, 'j� G c �n OWNER ADDRESS 1'� L36 4. Z E J 1 CITY/STATE/ZIP G� . 'qS33D CONTRACTOR S_eA t\ PHONE CONTRACTOR ADDRESS — CITY/STATE/ZIP LICENSE ❑ C-42 ❑, C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: � �� ft GEOGRAPHICAL INFORMATION: Coordinates X_ Y _] PERC TEST # BUILDING PERMIT# 0 &0&&ZX LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM a DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE Li COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: (� 1 I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �7 (� SEPTIC TANK TYPE/MFG P d. CAPACITY Uc/t1 gal #OF COMPARTMENTS °L ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION- ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP. ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS _ #OF LINES 3 LENGTH OF LINES J S ft DISTANCE TO NEAREST WELLV� G a' ft FOUNDATION 10 jr ft PROPERTY LINE f� k 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 It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH _ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It s SEEPAGE PITS NUMBER WIDTH 42- -ft DEPTH 21S ft DISTANCE To NEAREST WELL i S 0 ' ft FOUNDATION 10 f ft PROPERTY LINE !U�� Y 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. MINIMUM-24 WUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE.__C)1�V\e� DATE 2 2,0( 77 J U IT 19. 1 MIT E N S M NT lun �— EPARTMENT USE ONLY Application Accepted Date e2 — Area —i Employee ID# mo J'/ Final Inspection By _ Date Z -q O SPECIAL(PERMIT-Approved by Character of Soil to Depth of 3 _ _ _ _ _ Pit/Sump Soil Chtaracter: _ COMMENTS �0t - - PE SC Received ec Amount I Permit/ Pate, Invoice# Permit IDI / C�d� I_ INFO B s Remitted Service Re uest# 42-01 / t w`�n _r y� I / 1 ).t L WA:? .V✓AiER TRTMNT SYSTEM PERM(. 515/17 ` / �� `�/��/