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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT oAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-FIEFUNDABLE PERMIT (:ALL (YU&) ybJ-/b;// FOR INSPECTIONS tXPIHE5 I Y EAR FROM DATE ISSUEI 'OB ADDRESS V cr CITY/ZIP A z 33G DISTANCE TO NEAREST �(/�� WIDTH FOUNDATION CROSS STREET DISTANCE TO APN SUMPS PARCEL SIZE }/� �U OWNER NAME1`7 y �j Ya�%LY.� %L� I /L%L PHONE U 4 - '7 Lr OWNER ADDRESS �\ 6yI J��CJ�" it r: CITY/STATE/ZIP A ` � d I�'r�.'F� /t�"�7� NUMBER LENGTH Z(: 7a 1 q'A^�-,�/��l�i'�7��I� NEAREST CONTRACTOR L�-1-'�Ii,V"��01 I7A�'�-1iC�/ PHONE CONTRACTOR ADDRESS c� l tel/ (1'�' ice% 1>P -L j%� CITY/STATE/ZIP I _ YY ✓G2iS1�+ t Q LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM T DESTRUCTION Qi_plZ INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG ❑ LIFT STATION ❑ LEACH LINES DISTANCE TO NEAREST: WELL SIZE _ TYPE OF PUMP LEACHING CHAMBERS CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS It FOUNDATION ft PROPERTY LINE ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES LENGTH OF LINES WELL DISTANCE TO NEAREST FILTER BED WIDTH LENGTH Permit/Code Se0ce a uest # DISTANCE TO NEAREST MOUNDED WIDTH FOUNDATION ft DISTANCE TO NEAREST SUMPS WIDTH ft DISTANCE TO NEAREST DISPOSAL PONDS WIDTH WELL DISTANCE TO NEAREST SEEPAGE PITS NUMBER LENGTH DISTANCE TO NEAREST CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS It FOUNDATION ft PROPERTY LINE ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES LENGTH OF LINES WELL SC INFO ft FOUNDATION ft LENGTH Permit/Code Se0ce a uest # Invoice # WELL ft FOUNDATION ft LENGTH Grp 5 WELL ft FOUNDATION ft LENGTH WELL It FOUNDATION ft LENGTH WELL ft FOUNDATION WIDTH WELL It FOUNDATION ft ft ft ft PROPERTY LINE DEPTH It PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPE"PJ�Ytt T/�� DEPTH It PROPERTY LINE 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. UR ADVANC SIGNED r�cnoc %'rill Icv. V vtlfi"- DATE In DEPARTMENT 11SE 4111NLY �,y� Application Accepted By Date Area lll Employee ID#n V Final Inspection By Date [1 SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 10 PE SC INFO Received B ec ash Amount Remitted Date Permit/Code Se0ce a uest # Invoice # Permit ID# S 1 Grp 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T