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y ONSITE WASTEWATER TREATMENT SYSTEM PERMIT •SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT JOB ADDRESS y CROSS STREETpAPPNN TYPE/MFG :6y1 -7f I1&(q —7, ' 3 �f PARCEL SIZE , OWNER NAME -'Q/ �+ 1I �'v� �� lO I� �+ kn!% c l�� PHONE gal # OF COMPARTMENTS OWNER ADDRESS _ - - -CITY/STATE/ZIP CONTRACTORC —Se LAX— PHONE `�j,�—� r CONTRACTOR ADDRESS `X';V, —CITY/STATE/ZIP / / / dL/ C//?1 eT'Gnr j^ LICENSE ❑ iC-42 n' C-36 OTHER NUMB[R-7-/_`S_ 7a-.. EXPIRATION DATE T /� U �/ `7 WATER TABLE DEPTH: �/� Vb ft GEOGRAPHICAL INFORMATION: Coordinates X Y IJ PERC TEST # BUILDING PERMIT LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION / REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT kfg; D OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: la NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG :6y1 -7f I1&(q _ CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _- CAPACITY gal # OF COMPARTMENTS ft 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 1 LEACHING CHAMBERS # of LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft Or FILTER BED WIDTH L ft LENGTH L� _ _ it DEPTH ft _ _ DISTANCE TO NEAREST WELL Z.0a t It FOUNDATION 5 c _ ft PROPERTY LINE ^ ft ❑ MOUNDED WIDTH ____ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH �i% ft DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LIIW ft ElSEEPAGE PITS NUMBER _ WIDTH------ ft DEPTH % ft _ DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPE) —C ft � I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANT SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICEj1SE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. weviltof Application Accepted By Final Inspection By ,E6 Character of Soil to Depth of 3 Ft: COMMENTS -, C i I -G !VV I l{..0 r1CldU1r1r-U r-Vri Uyor-C411V/V.7 - I-LGF10C L,^I-6 Icvz/ a.0a-I vii - ---- - TITLE �jDATE S-) I- tYAH I MC IV / U.-IJE VIV 1. r Date Area Employee Employee ID#�� Date �_ Cl SPECIAL PERMIT -Approved by Pit/Sump Soil Character: PE SC INFO Received B Check ash Amount Remitted D to Permit/Code Service Request #4z* Invoice # Permit ID# a0zj 7�-O/ 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 v: