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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />PE <br />Code <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 Y AR FROM TE ISSUE <br />JOB ADDRESS ' 1 > <br />CO 2?0— <br />O S II j ( J CITY/ZIP <br />Invoice # <br />CROSS STREET J)E(Al <br />(�a.%D <br />APN ' Q <br />103Zzo <br />` PARCELSIZE <br />OWNER NAME Pe%,jL <br />/ ,4 Gf <br />� <br />Q <br />PHONE `V-7 - -5')- <br />5'OWNC <br />ER ADDRESS S rNn 4 <br />OWNER <br />J <br />iA "JQ &Z# CITY/STATE/ZIP <br />CONTRACTOR W 6_S_T <br />11AJ L' _- PHONE <br />" -7 <br />CONTRACTOR ADDRESS 33 <br />CITY/STATE/ZIP ca C)% <br />LICENSE ❑. C-42 ❑ C-36 OTHER A NUMBER It S 7 EXPIRATION DATE._ 20 ZJ <br />i <br />WATER TABLE DEPTH:yI—IJV ft GEOGRAPHICAL INFORMATION: Coordinates X Y_ <br />IJ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNEI <br />X REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ^,RESIDENCE iI COMMERCIAL[I[IOTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />Ck SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />TE <br />i l"13 <br />CAPACITY gal # OF COMPARTMENTS L <br />CAPACITY gal # OF COMPARTMENTS <br />� <br />DISTANCE TO NEAREST: WELL ft FOUNDATION_ r ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES 'X LEACHING CHAMBERS I N fO N i AIV # OF LINES Z LENGTH OF LINES S45 ft <br />DISTANCE TO NEAREST WELL ) 1;1� ft FOUNDATION to ft PROPERTY LINE S ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH _ ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_ ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ��F® <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH eft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 2O1Rt <br />❑ DISPOSAL. PONDS WIDTH ft LENGTH ft DEPTH ANJO fifty <br />DISTANCE TO NEAREST WELL � ft FOUNDATION ft PROPERTY LINEJ9 IRD���ANM j� TY <br />SEEPAGE PITS NUMBER <br />I WIDTH .7 ft DEPTH 2'S '�'1 UEPARTMENn <br />DISTANCE TO NEAREST WELL �O� ft FOUNDATION I S + ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />Application Accepted By' <br />Final Inspection By <br />Character of Soil to Depth <br />COMMENTS h Y1 <br />'vn a'rvJrct.I www - r-L.cnoc �.ncc �cvai pari vii <br />TITLE _�7C0 06- I DATE L`'1 <br />TMENT SE NLy <br />6*— <br />Date � Area Employee ID#� <br />Date ❑ SPECIAL PERMIT - Approved by <br />�> PRISU p Soil Character: <br />�� <br />-3 �� . A f 1 '�_ c/ �'i <br />o/C-L. .01%�-�/y r v I <br />9.e A '-_ .4" r1.11—� TF7(.1.wt L.N� gtr � i ^c. 4CPC <br />G4� <br />l <br />0 <br />42-01 �S� b ] ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ Amount <br />Cash emitted <br />Date <br />Permit! <br />Service Request # <br />Invoice # <br />Permit ID# <br />Z4 <br />Sp. w 391I - <br />G4� <br />l <br />0 <br />42-01 �S� b ] ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />