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t ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT p '^CALL X2/09 953-769_7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I _C _1_2QC CITY21P arnpa CROSS STREET ' Co ll ger P, APN -- � 3(e-- , PARCELSIZE 91 p> �f V v z OWNER NAME �eI7T:)at1 - _ PHONE OWNER ADDRESS 357cl 17 C hetokee CITY/STATE/ZIP G_d7_. /^�C� e r� CONTRACTOR 1X��1• �' v��/�•' _ G ____ ____ ____ _ ___ PHONE�Q�– 10 ` 'Od / t CONTRACTOR ADDRESS —3 _`/ Tw__r-4 ( 7 Ale - D. _----CITY/STATE/ZIP LICENSE 11 42 ❑' 'C-36 OTHER NUMBER- �7 O#Z EXPIRATION DATE_______ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X_ Y 11 PERC TEST # BUILDING PERMIT#J O LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/AUDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL I.I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:___.. 3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG _Ldd� Q 3 �+ CAPACITY _ gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS -�-- — L, DISTANCE TO NEAREST: WELL ao ft FOUNDATION ft PROPERTY LINE T Q tt ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES 11 LEACHING CHAMBERS _ #OF LINES _ LENGTH OF LINES ft DISTANCE TO NEAREST WELL /y30 ft FOUNDATION ICI ft PROPERTY LINE 35 ' 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 It FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER L WIDTH ft DEPTH as ft DISTANCE TO NEAREST WELL--1-70 'ft FOUNDATION �QO ft PROPERTY LINE �S 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE____ �� _ DATE S' —cPO T 1-711 r7 rA DEPARTMEN U E ONLYENT Application Accepted By �- !- Date S � ZOi0 Area y Employee ID# DA Final Inspection By _ Date _Sl 2of � ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: _ _ _ __ Pit/Sump Soil Character: COMMENTS Ae, ,J LFR. `&, _ __ /Vo (�!/1 S�ie- o(J w (L 1O ta wi T v�.`-1✓ _ 629 PE SC Received ec Amount Date Permit/ Invoice# Permit ID# Code INFO By Cash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17