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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN J-AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS l V,� )�� 1� 11 , S :w� 49-CA CITY/ZIP S d Gk hi �J I ,� �/� CROSS STREET APN /�,.�L�� c 1 PARCEL SIZE p �1V C_ PHON f� E-I H OWNER NAME Kp5 O 1 } yn /� (� OWNER ADDRESS 4 / /'� b l S (-QS �d CITY/STATE/ZIP �,c ` /�k.r[V 11 CSA CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I C-42 I I C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates 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: 11 RESIDENCE 1.1 COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMB/ER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG L--- APACITY gal #OF COMPARTMENTS .t ❑ GREASE TRAP TYPE/MFG 6 APAACITT gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL fr 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 LENGTH OF LINES It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE p� ft L3 MOUNDED WIDTH ft LENGTH ft DEPTH PV. ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 11.. LI SUMPS WIDTH ft LENGTH ft DEPTH 'koklMi ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH s.-_ I m ft VVj DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN t QU � ft , ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH -ria',A_MEN7; IV n' ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �RTMENr 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR IN PECTIONS-PLEASE CALL 209 953-7697 SIGNED / TITLE DATE PARTMENT USE NLV �} r Application Accepted By Date Area -1 Employee ID# �a r Final Inspection By Datel—/O 1 F SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pi Sum Soil Character: COMMENTS C 1tic1 fA rn Wil.(, r PE SC Received ec Amount Date Permit/ Invoice# Permit ID# Code INFO By ---vasn Remitted Service Request# 0510 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17