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JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />S'U 6-10t A') OWNER ADDRESS <br />APN <br />oc r <br />Ja4,Q ,„ <br />H Amtio0 coim EALTH , ineok <br />6,d Sow 1 8 2022 <br />TY EpAR ,ivz.NT <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STocKTON CA 95205 -(209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP e--1--71c-v 17n / <br /> PARCEL SIZE 1' i 7 <br />CITY/STATE/ZIP 4 i-e-c/4-1 e 4 .75773 C, <br />EXPIRATION DATE <br />WATER TABLE DEPTH: ft <br /> <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Li PERC TEST # <br /> <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />REPLACEMENT 1- ilk <br />REPAIR/ADDITION <br />OUT-OF-SERVICE SEPTIC SYSTEM <br />ENGINEER DESIGNED /ALTERNATIVE <br />DESTRUCTION -tcI1 k <br />INSTALLATION WILL SERVE: L1,--4SIDENCE <br />NUMBER OF LIVING UNITS: <br />II COMMERCIAL <br />NUMBER OF BEDROOMS: <br />E OTHER <br />NUMBER OF EMPLOYEES: <br />0 <br />0 <br />1:1".-S-EPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL S-0 ft FOUNDATION S. ft PROPERTY LINE c ft <br />LIFT STATION SIZE TYPE OF PUMP 1:1 PKG TX PLANT U SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />0 LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />El FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 WIDTH MOUNDED ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 SUMPS ft WIDTH LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br />SIGNED TITLE C., 0 /7 ,INT 44 r DATE (6 ( e., .;4, <br />PA ym Rec. eh, <br />CONTRACTOR viA ()4(-5 t(ziz <br />CONTRACTOR ADDRESS .t?)c?c C-n <br />PHONE <br />CITY/STATE/ZIP gt-tc_JC ) <br />PHONE <br />LICENSE 0 1 1C-42 Lii C-36 OTHER NUMBER ____ :SS3HOUV iLlS DEPARTMENT 1.1Sf ONLY <br />Date /0/44(,42 Area <br />Date /040/2 2 CI SPECIAL PERMIT -Approved by <br />Application Accepted By <br />Final Inspection By <br /> <br />SIA-S3y0c; <br />Employee ID# <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS ()irk frorined eir <br />Pit/Sump Soil Character: <br />nk n3e)Iy <br />PE <br />Code <br />SC <br />INFO <br />Received A Chec Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Permit ID# <br />40061 HS— /67/8". .t3ia 1011 '2? 3120D$S9 I k <br />42-01 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17