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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLEPERMITCALL 209 953-7697FOR INSPECTIONS �l EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2 11 � � ��=� O� (){J�/ CITY21P y'Al� CROSS STREET Lt bbt IV APN "- /-I oD- 19 PARCEL SIZE '� > OWNER NAME SAt—. My�yZ PHONE w OWNERADDRE�.SS_`'F-S'7 SAnfT �� r�(� I�4� CITY/STATE21P CONTRACTORyv`S I7L�^5� `�7A Li4tAW-1�1('j`-- PHONE ^J r l CONTRACTOR ADDRESS ✓� MM-L-0\ S f r CC�I CITY/STATE/LP L-A')�- S Z.�`-' ri LICENSE '_1 C42 J_C-36 OTHER NUMBER eS(t51 EXPIRATIONDATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 11 PERC TEST # BUILDING PERMIT#15�105 LAND USE APPLICATION# J` TYPE OF WORK: NEW INSTALLATION i REPAIR/ADDITION L ENGINEER DESIGNED/ALTERNATIVE V U REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I:: DESTRUCTION INSTALLATION WILL SERVE: _ RESIDENCE ❑ CCMMERCIAL 71 OTHER (� NUMBER OF LIVING UNITS: (� NUMBER OF BEDROOMS: 1 '\ NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG t CAPACITY `b- J81 #OF COMPARTMENTS G ❑ GREASE TRAP TYPE/MFG CAPACITY gal It OF COMPARTMENTS DISTANCE TO NEAREST: WELL I JJ ft FOUNDATION It PROPERTY LINE SQ' It ❑ LIFT STATION SIZE _TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) / pr c ❑ LEACH LINES Y.,LEACHING CHAMBERS 1 N\1\}t KfU #OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL FOUNDATION ft PROPERTY LINE �_ It ❑ FILTER BED WIDTH It LENGTH ft DEPTH It 1 DISTANCETONEAREST WELL ft FOUNDATION It PROPERTY LINE ft JJ ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft L ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft I DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER '1� WIDTH yri 1 _ft DEPTH LS ft DISTANCE TO NEAREST ' WELL <<Y.> 11 FOUNDATION I ft PROPERTY LINE I J 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 48 HOUR A TICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE �1 rJ t J rI DATE V1. Z U J3 7Y J ti M NT I / DEPARTMENTU O Y 99 Application Accepted B � � Dale Area Employee ID# Final Inspection By Date r, $PECIPERMIT-Approved oy Charactar of Soil to th i "A haracter. COMMENTS � � /✓t 7. r _ 1 O PE/ SC Recely Check!!/ Amount Date PermlU InvoicaN Perm#ION Cade INFO aah m'tmt11-1 IttbLrf Service Re uestN ({�S 42-01 ��/"` ONSITE WASTEWATER TRTMNT SYSTEM PERMIT —118