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ONSITE WASTEWATER TREA 1-MErNT SYSTEM PERMIT 041 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE/PLERMIT E;AL{L� ZU`J (� `Jb3-/bJ/FOR INSPECTIONS ALXPIREeS 7 YEAR FROM DATE ISSU JOB ADDRESS f V C GJ 11 1 �+y ,`J t A(-,\ �' \�°'C:�§yfzIP �,+�a./V I�U <Z t CROSS STREET �l�+y�I ' .} APN dl! // f- / PARCEL SIZE l �� OWNER NAME_ t]�i*n `'. rte!` 1C [ ! o 17n�✓P� zs 4-4 P 0NE_'7� 5 OWNER ADDRESS SAr. 4 A � ^V%j (w CITY/STATE/ZIP CONTRACTOR W FiS1 �A�"Y't �yL'N �E PHONE 33"1 13°) 4 /yj� CONTRACTOR ADDRESS f `rY*w �/' V S � _ CITY/STATE/ZIP Leo � C^ �lS Let LICENSE C / _ C-42 ! I C-36 OTHER NUMBER v45 %)5r7 EXPIRATION DATE 1 -7 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ _- Y PERC TEST # BUILDING PERMIT # _ ... LAND USE APPLICATION TYPE OF WORK: NEW INSTALLATION LI REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I 1 OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: J RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:_' n 7 3 ❑ SEPTICTANK TYPE/MFG yd'V CAPACITY 15w gal # OF COMPARTMENTS ` ❑ GREASE TRAP TYPE/MFG CAPACITY _ gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ICK3 ft FOUNDATION �J it PROPERTY LINE gL?__ - _ _ft ❑ LIFT STATION SIZE _ TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS t Nh (� t� # OF LINES LENGTH OF LINES 4 ft DISTANCE TO NEAREST WELL t ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 13A ft ❑ MOUNDED WIDTH _ ft LENGTH ft DEPTH_ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH �(• DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH —/C�1f� jO'`�01— Pk ON SOUAh DISTANCE TO NEAREST WELL FO NDATION ft PROPERTY LINE 9K SEEPAGE PITS NUMBER _ _ WIDTH PA�Nri fvr —. ft ft DEPTH ZS , At DISTANCE TO NEAREST WELL S7 ft FOUNDATION V ft PROPERTY LINE l5 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 A14D TIIAI- 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 1 Application Accepted By Final Inspection By� ( DEPARTMENTUSE ONLY _ Date Area Employee ID# o� Date 1 w2 LlSPECIAL PER IT Approved by Pit/Stimn Soil Character: +o V"t- PE SC Received Amount D to Permit/ Invoice # Permit ID# Code INFO B Cash Remitted ServiceRe # a7A t] ((u��est 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17