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W, ONSITE WASTEWATER TREATMENT SYSTEM PERMIT /�/✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT AlALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Yv1 t G� CITY/ZIP T^� C'J« " CROSS STREET34-1 � 910 APN �_ { �O l! L PARCELSIZE OWNER NAME 4.014 Z 63Ac. �s r6 ��f /iL'�"�`ry PHONE OWNER ADDRESSkK So'� ��/72 i5��—��4'i CITY/STATE/ZIP CONTRACTOR Y 1 1 1 14-e-5 L tjgo-�4< 4 3 'c -.S-C-4PHONE CONTRACTOR ADDRESS 'J/� CS}[" (i2 s tS f j CITY/STATE/ZIP Mtwig CG LICENSE 1 1 C-42 I f C-36 OTHER P f 7 NUMBER T it EXPIRATION DATE twi g WATER TABLE DEPTH:(/V - J O ft GEOGRAPHICAL INFORMATION: COordin tes X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL IJ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 ) NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG 'tL CAPACITY _{ d 25 gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS yy ; DISTANCE TO NEAREST: WELL # L 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 n� LENGTH OF LINES too ft DISTANCE TO NEAREST WELL I4�� ft FOUNDATION iJ ft PROPERTY LINE 75/ ft ❑ FILTER BED WIDTH ft LENGTH D to Permit/ Service Request # ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINET ft El sumps SUMPS WIDTH ft LENGTH ft DEPTH —If 1!,!! ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft DISPOSAL PONDS WIDTH El DISPOSAL ft LENGTH ft DEPTH IY i ' to ft DISTANCE DISTANCE TO NEAREST WELL ft FOUNDATION &. ft PROPERTY LI- U►f- ft E] SEEPAGE PITS NUMBER WIDTH ft DEPTH ENVfR•,U�N 000NTyft DISTANCE TO NEAREST WELL ft FOUNDATION H ft PROPERTY A LTN or ��AL ft fNE" DEPADT.. .._ 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. rvinvlrvluff Ivvn /YL/YF1/Y\1L Ivv I1a+L "J--wurnL✓ rvn I/YJrLIi I IV/YJ - rLLriJC L/HLL LVJ DUJ-/V.7/ SIGNED / TITLE C-011 J00'ice DATE Application Accepted By Date Area J Employee ID# Final Inspection ByDate7� LlSPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE Code SC Received INFO B hec ash Amount Remitted D to Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 U Y v v