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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAt` WN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 QCj1-TIEFUNDABLE JOB ADDRESS CROSS STREET MIT,' � yy{CAL`L 209 953-7697FOR INSPEC TIONS EXPIRES 1 YEAR FROM DATE ISSUEI .) W L � �"-Ji7 - II L i Lor ->I, CITY/ZIP �Li� C /�� ,}� APN [17-�—.jPu OWNER NAME /-!1,//C.l�IA�L QA�I�`J W){�Al'"Y 6rld J c6re/1e -b Ph�Ill ONE�� OWNER ADDRESS � y�"7A� `'�y t' CITY/STATE/ZIP CONTRACTOR VV -T G.7�'!y7 ��tKN�1t J INL - PHONE zJC) 13 o) - 77)A CONTRACTOR ADDRESS 33 j y CITY/STATE21P LOAD X CA LICENSE E C-42 ❑ CIC -36 OTHER A NUMBER __ �+ -" i_%S-7 EXPIRATION DATE 201 V WATER TABLE DEPTH: / y ft GEOGRAPHICAL INFORMATION: CI PERC TEST # BUILDING PERMIT # TYPE OF WORK: 7C NEW INSTALLATION I REPAIR/ADD SIZE 1)S240 X -- - - - Y D USE APPLICATION # ENGINEER DESK REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM rl DESTRUCTION _ TERNATIVE INSTALLATION WILL SERVE: ❑ RESIDENCE "COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:_ 7'- SEPTIC TANK ❑ GREASE TRAP xLIFT STATION TYPE/MFG 4V)} ` CAPACITY Z gal # OF COMPARTMENTS TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION _ ft PROPERTY LINE zC�:' ft SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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 By _ Final Inspection By� Character of Soil to Depth of 3 Ft: COMMENTS Date Date 'OR INSPECTIONS - PLEASE CALL (209) 953-7697 TITLE t� 1:+� 1 _ __. DATE 4' 13 i F—_ T US il O AJ LY — Area Employee ID# �Z ❑ SPECIAL PERMIT - Approved by Pit/Sump Soii Characier: PE Codp LEACH LINES 'A LEACHING CHAMBERS _ I -J f•lA t K -ft' # OF LINES I _ LENGTH OF LINES �c ft Permlt ID# DISTANCE TO NEAREST WELL 1 SJ ft FOUNDATION 10' ft PROPERTY LINE 7 , _ ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It 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 LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH _ ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION _ it PROPERTYLINE 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. SIGNED Application Accepted By _ Final Inspection By� Character of Soil to Depth of 3 Ft: COMMENTS Date Date 'OR INSPECTIONS - PLEASE CALL (209) 953-7697 TITLE t� 1:+� 1 _ __. DATE 4' 13 i F—_ T US il O AJ LY — Area Employee ID# �Z ❑ SPECIAL PERMIT - Approved by Pit/Sump Soii Characier: PE Codp SC INFO Received By eckAmount Cash Remitted Date Permit Service Re uest # Invoice # Permlt ID# *(-z32- "` 4113 119' 3 01 7 9 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17