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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT -' e SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 1yUN-r1tt-UNUACLt rEHMIT ^ GALL (ZU9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS /-7� 1) I O /I � ri O'er r J � _ _ CITY/ZIP �l /Lf�--Y G � q5 Z�� CROSS STREET Arc, Li d q iei APN O L) I U PARCEL SIZE O' OWNER NAME N A �tf 6l1/, q ` PHONE /o OWNER ADDRESS 17 G („ fron4 Sir' _ __CITY/STATE/ZIP -L Y1 b �� `o CONTRACTOR lL� A acic b &." 4Zcr PHONE 11� 1.s''2B G s p CONTRACTOR ADDRESS tgOk so CITY/STATE/ZIP �'Yi�� fto•� /:►V�' `�� _ LICENSE ❑EC -42 I I C-36 OTHER 4 NUMBER EXPIRATION DATEh� WATER TABLE DEPTH: �) i% ft GEOGRAPHICAL INFORMATION: Coordinates X Y 11 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: G,-IIEsIDENCE IJ COMMERCIAL E OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG t ✓ S t iA f/ CAPACITY TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION SIZE TYPE OF PUMP ❑ PKG TX PLANT 9' LEACH LINES LEACHING CHAMBERS gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES ( LENGTH OF LINES 440 I ft DISTANCE TO NEAREST WELL Pad t- It FOUNDATION L10' It PROPERTY LINE 010' ft FILTER BED WIDTH SC Received INFO B ft LENGTH Permit/ Service Request # Invoice # ft DEPTH ft DISTANCE TO NEAREST WELL q ft FOUNDATION ft PROPERTY LINE ft MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROnPERTY LINE ft {Y SEEPAGE PITS NUMBER WIDT 3&" ft DEPTH d`'J�I ft DISTANCE TO NEAREST WELL ft FOUNDATION I �t ft PROPERTY LINEj0' 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 COMPENSADION LAWS. 7- &IINIMUM-i'KHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE Gc711 ti CL i` DATE ' tYAHIMtNI U5t UIVLY Application Accepted By Date 1 l' I Area 9 Employee ID# Final Inspection By Date : ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth o 3 Ft: Pit/Sump Soil Character: COMMENTS OU) i Ij . 141N d ;c'7 PE SC Received INFO B Check#/ Amount Cash Remitted Date Permit/ Service Request # Invoice # Permit ID# ��la is 0 30� Q q 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17