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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 IVUN-r1tf-UNUA8LE VEHMIT (:ALL ZU9 953-7697 FOR INSPECTIONS /� EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS G' CITY/ZIP bi «t'1 = P CROSS STREET �l'i'-e� l APN I "1 PARCEL SIZE q OWNER NAME �fiC.V'�'+Sry �1��(� P'I `.0 Si-/� c t R PHONE a no _ y1 S OWNER ADDRESS �« �.Ci CITY/STATE/ZIP _RAAct,e /G� -no 3' CONTRACTOR t CL.ei�tlC:il40 PHONE s l��=.�(��r� A r CONTRACTOR ADDRESS �� CITY/STATE/ZIP L! h,44,.eg_ 14::54 ( W-� LICENSE _ C-42 I 1 C-36 OTHER NUMBER JC``'�`� EXPIRATION DATE JI1 yC WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: 1 PERC TEST # BUILDING PERMIT # r() Coordinates X Y LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 1 RESIDENCE I_I COMMERCIAL `# HER f N_UmBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG P-�7L CAPACITY 7j6 gal # OF COMPARTMENTS�� ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL 166, ft FOUNDATION �O t ft PROPERTY LINE �, ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) Pe -LEACH LINES LEACHING CHAMBERS e r # OF LINES k LENGTH OF LINES Va) l ft V WELL %6 I ft FOUNDATION 161 ft PROPERTY LINE 10 ! ft ft LENGTH ft DEPTH ft WELL ft FOUNDATION ft PROPERTY LINE It ft LENGTH ft DEPTH ft WELL ft FOUNDATION ft PROPERTY LINE ®lr.-_ ft ft LENGTH ft DEPTH - � ► ;=t WELL ft FOUNDATION ft PROPERTY LINE ft LENGTH _ ft DEPTH P ��LL.•//ft WELL ft FOUNDATION ft PROPERTY LINE ��nts ft WIDTH ft DEPTH �NJOA1,,,.. _ ft WELL ft FOUNDATION ft PROPERTY LIgIR�NM� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S -AIV 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. SIGNED Application Accepted By I Final Inspection By Character of Soil to Dep of COMMENTS WOO wn ►IW Jr CV IIWIVO - r-LCmolz VMLL IGU3/,JO-/U9/ TITLE r DATE y D% I (L DEPARTMENT USE ONLY Jill Date 4 - IArea + Employee ID# A h ryi f Date � F- SPECIAL PERMIT - Approved by kv- Pit/Sump Soil Character: ! 1 � PE Code DISTANCE TO NEAREST FILTER BED WIDTH Date Permit/ Service Request # DISTANCE TO NEAREST MOUNDED WIDTH DISTANCE TO NEAREST SUMPS WIDTH DISTANCE TO NEAREST DISPOSAL PONDS WIDTH DISTANCE TO NEAREST SEEPAGE PITS NUMBER DISTANCE TO NEAREST e r # OF LINES k LENGTH OF LINES Va) l ft V WELL %6 I ft FOUNDATION 161 ft PROPERTY LINE 10 ! ft ft LENGTH ft DEPTH ft WELL ft FOUNDATION ft PROPERTY LINE It ft LENGTH ft DEPTH ft WELL ft FOUNDATION ft PROPERTY LINE ®lr.-_ ft ft LENGTH ft DEPTH - � ► ;=t WELL ft FOUNDATION ft PROPERTY LINE ft LENGTH _ ft DEPTH P ��LL.•//ft WELL ft FOUNDATION ft PROPERTY LINE ��nts ft WIDTH ft DEPTH �NJOA1,,,.. _ ft WELL ft FOUNDATION ft PROPERTY LIgIR�NM� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S -AIV 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. SIGNED Application Accepted By I Final Inspection By Character of Soil to Dep of COMMENTS WOO wn ►IW Jr CV IIWIVO - r-LCmolz VMLL IGU3/,JO-/U9/ TITLE r DATE y D% I (L DEPARTMENT USE ONLY Jill Date 4 - IArea + Employee ID# A h ryi f Date � F- SPECIAL PERMIT - Approved by kv- Pit/Sump Soil Character: ! 1 � PE Code SC INFO Received B Che Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# �,► � JJ � s s � «- S� aG7 IS 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T m Y 0 z m