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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Ff SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVUN-rIEFUNUAtiLE PERMIT L:ALL ZU9 953-1691 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS I �Pr t1 O �n CITY/ZIP 'i'1 en.4 to --e-4 c:y� CROSS STREET l Y f / APN �� O " C'1 PARCEL SIZE S OWNER NAME rI L Lr C� �CrrLi� D J �CXi/C�r`/G� y / r kxe, • 1 R PHONE OWNER ADDRESS Lq ^^Ar i<-CITY/STATE/ZIP Y I G� /�� CONTRACTOR � / 1 . bLL (S 13-ewt;Ich/ a�+� St, r. PHONE � ev � _196 CONTRACTOR ADDRESS ik_) i8ow Cid V NUMBER -CITY/STATE/ZIP �11c=vt �t ? ��¢ !J J � LICENSE I I C-42 C-36 OTHER � NUMBER lid r 0 -'+T --T EXPIRATION DATE / (� 112 — ✓ 1 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y L PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESI( REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION NED /ALTERNATIVE INSTALLATION WILL SERVE: Q/f{E-SIDENCE L COMMERCIAL I I OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP i LEACH LINES LEACHING CHAMBERS WELL ant ft ft LENGTH CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES a LENGTH OF LINES b Cif ft FOUNDATION to I ft PROPERTY LINE %s fi ft ft DEPTH ft WELL DISTANCE TO NEAREST FILTER BED WIDTH ft PROPERTY LINE ft DISTANCE TO NEAREST MOUNDED WIDTH ft DEPTH DISTANCE TO NEAREST SUMPS WIDTH FOUNDATION DISTANCE TO NEAREST DISPOSAL PONDS WIDTH DISTANCE TO NEAREST SEEPAGE PITS NUMBER ft DISTANCE TO NEAREST WELL ant ft ft LENGTH CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES a LENGTH OF LINES b Cif ft FOUNDATION to I ft PROPERTY LINE %s fi ft ft DEPTH ft WELL SC INFO ft FOUNDATION Amount Remitted ft PROPERTY LINE ft _ ft LENGTH -A:24 0 >"" ft DEPTH ft WELL SKCO'7$q.-L:7�t> ft FOUNDATION ft PROPERTY LINE ft ft LENGTH ft DEPTH WELL ft FOUNDATION ft PROPERTY LINE/ ft LENGTH ft DEPTH ft WELL ft FOUNDATION ft PROPERTY LIN ft _ WIDTH ft DEPTH /Z�cPOAO ft VIR WELL ft FOUNDAI ION ft PROPERTY LIfJLCAf_ T}�M N^1}Tt I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH ON JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 H!Ryg ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE �%1'�'%C=c- �rJ DATE DEPARTMENT USE ONLY _ Application Accepted By Date- J Area `J S y Employee ID# Final Inspection By Date. SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: c�s y /,gz ._ Pit/Sump Soil Character: COMMENTS PE Code SC INFO Received By Chec ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# -A:24 0 >"" Z g gw SKCO'7$q.-L:7�t> .11 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17