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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN 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 -J� -1 ii f_4`� ` No t_f,/,J(L CI Y IP CROSS STREET CJ A� W '-+� APN 09 PARCEL SIZE 0. Y C OWNER NAME VL meS% 7 PHONE v'� 7 T � ^ J OWNER ADDRESS S RTM��/��C S (L�,Ab J J \ CITY/STATE/ZIP �I�C� 5/� C/'' CONTRACTOR VJ )12\J�/�� -f VR� c �,'y + � PHONE 330)- -7'3 )!l �1 CONTRACTOR ADDRESS 3� /�� J��L�T CITY/STATE/ZIP v/t LICENSE C-42 I C-36 OTHER / NUMBER �� EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y Cl PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: A RESIDENCE I I COMMERCIAL ✓, I OTHER NUMBER OF LIVING UNITS: NUMBER of BEDROOMS' — <J NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG L -?., TA— APACITY% VLO-` gal #OF COMPARTMENTS 'Ll LJ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS � i DISTANCE TO NEAREST: WELL �� ft FOUNDATION S ft PROPERTY LINE {J t ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS D N'(1 } n�`� #OF LINES'_ LENGTH OF LINES S2 i ft r DISTANCE TO NEAREST WELL FXD ft FOUNDATION ft PROPERTY LINE S ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER WIDTH 3 ft DEPTH Z� ft DISTANCE To NEAREST WELL 13-i ft FOUNDATION Z,l 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 a SIGNED _ TITLE DATE 1 L-!)� —i 1 1 I' 1 ' N H rL,/ 0 EPARTMENT U E ONLY Application Accepted By Date Area Employee ID#� Final inspection by IT— Date z SPECIAL PERMIT-Approved by Character of Soil to Depth of jF . Pit/ ump So' Character: COMMENTS jVEYI M'A 0A1, PE SC Received hec /' Amount Date Permit/ Invoice# Permit ID# Code INFO B ash emitted Service Request# 09, Fo b c� _ll 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17