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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALI H DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUND T,- 0 CALL 209 953-7697 FOR INSPECTIONSI. EXPIRES 1 YEAR FIROMEIMEASWED JOB ADDRESS, I k -__ ___ C /ZIP, .. m T CROSS STREAyP�N�_}�'� !--///��///'�� _-...__1.__.-._PARCEL SIZE Y j OWNER NAMHONE E r 6 `' T'�_ ...... _ _ ._ .JV•1`D �r _ ��T- •',+��. �- 8)t OWNER ADDR S __ I _`/ _._-_CITY/STATE2IP _ CONTRACTOR-,_ ` ^q_li,� �`� PHONE_� �C}�Cr� CONTRACTOR ADDRESS 46M.-W�... uA ISC:..........1-... _..._.__. _CITY/-TATEIZIP.................. LICENSE C-42 I C-36 OTHER—jNUMBER j_ ATiomDATE .........FIV7- WATERWATER TABLE DEPTH !'A It GEOGRAPHICAL INFORMATION: Coordinates X.. PERC TEST NI BUILDING PERMIT#-_.-. _-_LAND USE APPLICATION TYPE OF WORK: NEW INSTALLATION REP AIHIAUDITION ENGINEER DESIGNED/ALTER IVE REPLACEMENT , OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTIO INSTALLATION WILL SERVE: RESIDENCE ;' COMMERCIAL !I OTHER NUMBER OF LNING UNITS: } __ NUMBER OF BEDROOMS:__.__._ ^ NUMBER OF EMPLOYEES: �tS SEPTIC TANK TYPEIMFG _ - __._. CAPACI I'Y _ �_ gal NOF COMPARTMENTS ❑ GREASE TRAP TYPE/Mr-G .__- - CAPAGI71' ..,__ _ gal N OF COMPARTMENTS r DISTANCE TO NEAREST: WELL M. It I01)NDArION ._ _ It PROPERTY LINE ,_h ❑ LIFT STATION SIZE ._......TYPE OF PUMP___.-_ Q PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS__,__---._ -. N or LINES LENGTH OF LINES it DISTANCE TO NEAREST WELL _- - it FOUNDATION. __it PROPERTY LINE ft ❑ FILTER BED WIDTH __ __._.it LENGTH_ _- ___--K DEPTH _.__ it DISTANCE TO NEAREST WELL_ _._ It FOUNDA110N _ --it PROPERTY LINE -.___ it ❑ MOUNDED WIDTH _.. _--it LENGTH _-.._.. ___—it DEPTH, it DISTANCE TO NEAREST WELL_---_---.-._ It FOUNDATION_._. _._it PROPERTY LI It (3 SUMPS WIDTH ___it LENGTH _... ._.._ __ .___ it DEPTH��it DISTANCE TO NEAREST WELL--___.- II FOUNDATIOIJ --II PROPERTY LW it ❑ DISPOSAL PONDS WIDTH it LENGTH........_........__....._....__._............._-__._tl DEPTH it DISTANCE TO NEAREST WELL _._ it FOUNDATION,...._ _.it PROPAW it ❑ SEEPAGE PITS NUMBER WIDTH,-.....__._._._..... 11 DEPTH Ilk �NVI VIN it DISTANCE TO NEAREST WELL ._._... II FOUNDATION---.-It PROPERTYLI �Nh -v....-.-. .._-.. .._-`._r..._.._..._-.-_...__..._....._ ------ r �_.._. I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKEFK COMPENSATION LA M! HaU IVA0041,MONCIRREQUIRED FOh' 10& 4A&MSE CALL(20a§5,3-749 SIGNED / '_ TI7U' DATE --- So ` I I E I I V f DEPAFTMFNT SE NLy Application Accepted By - Date_ O_ Area Employee ID#_ Final Inspection By ' •7� Date ,Q�t�:L F1 SPE IAL PERMIT-Approved by --'--- Character of Soil to Depth of 3 Ft:_..___.. / 7--�-- J Pit/Sump Soil Character: COMMENTS'fl�� Z . D LCA - +yK PE SC Received Amount Date Permit' Invoice N Permit ID# Code INFO B i s Remitted Servce Request N -- - - UNSITF-WASTEWATER TRTMNT SYSTEM PERMIT 42.01 5&17