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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT F.,/( SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 I)1UN-r1tl-UNUAt3Lt PERMIT (;ALL ZU9 95.3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS 1 J VAn' ll e i )Z -CITY/ZIP CROSS STREET' /l�D APN C PARC L OWNER NAME _/Q [ / i, s- ,)a PHONE OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRES! LICENSE VIC"_42 G9 �2 4 .6 I I C-36 OTHER CITY/STATE/ZIP 'FseadA I, Pr PHONE .2��`617'r-61392- /� Q CITY/STATE/ZIP jO� A A�r�[.n/E,�� NUMBER O �� EXPIRATION DATE 45h r WATER TABLE DEPTH: 1) / `7 U ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE I// REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE I I COMMERCIAL L OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS 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 # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL�&14 ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL_ 6C'_4_ ft FOUNDATION ft PROPERTY LINE ft r (17 SUMPS �� WIDTH ft LENGTH 49 ft DEPTH S / ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. MINIMVM 2 HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED 36"wz w TITLE 4W A e y' DATE 3 _d _/y/ Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS -77-r-_ f - '(T Date Date I S' L Y Area Employee ID# ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE Code SC INFO Received By Check ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# (� 4V�I�i$ 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17