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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-REFUNDABLE PERMIT L:ALL lUJ 9bJ-/bJ/FORINSPECTIONS LXPIRES 1 YEAR FROM L)A�TE ISSUEI JOB ADDRESS C 9-0tir ST CITY/ZIP CROSS STREET 9-'b APN dq \3t/ - "77o PARCEL SIZE 0, C19 A -L OWNER NAME SAmmx Coy, __ __ __ PHONE %61414,__"B1 OWNER ADDRESS ,.�� O q0*4.-`► CITY/STATE/ZIP L�Nfl�►� . t �iSz3 L CONTRACTOR \ S Y-"fGS-r PHONE Zoa 1 q4Z. i36o CONTRACTOR ADDRESS Po Sc* k59Z _ _ _ CITY/STATE/ZIP l.1-� Gr a5-L3(o LICENSE _i 'C-42 ❑I IC -36 OTHER A4-,5 NUMBER g7A00I EXPIRATION DATE /43h/ Ay WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/AL' ERNATIVE ft REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION LINSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: 'J6- SEPTIC TANK TYPE/MFG C .G' Cf `� L CO 14 -- CAPACITY DO _ gal # OF COMPARTMENTS �L ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS FOUNDATION DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Received Check# ash # OF LINES Date LENGTH OF LINES Invoice # DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ 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 It FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft 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. SIGNED Application Accepted_ 18y �q Final Inspection By O Character of Soil to Depth of 3 COMMENTS 2164,4 FOR INSPECTIONS - TITLE_ Dates 7,VArea. Date ❑ SPw Pit/Sump Soil Character: DATE 4- I S i + t Employee ID# ERMIT - Approved by 171 ft ft ft ft ft ft It ft ft ft ft PE Code SC INFO Received Check# ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 211L41' `I 42-01 5/5/17 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT r