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ONSITE WASTEWATER TREATME=NT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HE ALT II DFPARI MEN 1868 E.HAZELTON AVI um -STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT 14CALL 209 953- 69_7 FOR INSPECTIONS EXPIR /ES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1' O y7CIITTYY21P 4IN QA" / 7Com. ]24--. _f CROSS STREET i V O /�'��n/7l L 11 -_ APN(/L/Z I D1_____ _PARCEL SQE - OWNER NAME �,•/Jecj< 1/Q N^bLk Cj he,r (P/.}r1ONE ,l `/� /J OWNER ADDRESS 1 O YQ X 4 • O CITY/STATEIZIP 14, r��N ` ly lc c CONTRACTOR --PHONE 4 CONTRACTOR ADDRESS _ CITYISTATE013 LICENSE C-42 ❑ C-36 OTHER TMSER_ _ - _ _EXPIRATioN DATE WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X_ _ Y IJ PERC TEST N BUILDING PERMIT# _ __ LAND USE APPLICATION N _ TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED IALTERNA X REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION l C_ INSTALLATION WILL SERVE: yI RESIDENCE II COMMERCIAL I OTHER_ NUMBER OF LIVING UNITS: . NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES:-- SEPTIC MPLOYEES: _SEPTIC TANK TYPF/MFG - __"_- CAPACITY gal #OF COMPARTMENTS_ _ ❑ GREASETRAP TYPF/MFG _ CAPACITY _ gal #OF COMPARTMENTS__ DISTANCE TO NEAREST: WELL 4 FOUNDATION_ 62 N PROPERTY LINE (Od E y II C)f LIFT STATION SIZE Q•¢ TYPE OF PUMPjejNG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) /❑ LEACH LINES LEACHING CHAMBERS_--_-_ #OF LINES LENGTH OF LINES 11 DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE_ fi FILTER BED ], WIDTH A 2t__it LENGTH 3G• S K DEPTH O w ft 8 D/ DISTANCE TO NEAREST WELL 1/0' _ it FOUNDATION !d R PROPERTY LINE Ly ❑ MOUNDED A WIDTH it LENGTH it DEPTH. It A DISTANCE TO NEAREST WELL — It FOUNDATION it PROPERTY LINE .. _ It ❑ SUMPS WIDTH _It LENGTH_ __ _ - __ it DEPTH ft DISTANCE To NEAREST WELLit FOUNDATION _it PROPERTY LINE IT ❑ DISPOSAL PONDS WIDTH it LENGTH—__ it DEPTH It DISTANCE TO NEAREST WELL __ it FOUNDATION R PROPERTY LINE_ It ❑ SEEPAGE PITS NUMBER Wom N DEPTH It DISTANCE To NEAREST WELL it FOUNDATION it PROPERTY UNE it I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND IILGIILATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICFNSF BOARD AND TIIAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIM M�4 H UR 1/ CE NOTIC REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 �A SIGNED TITLE 1_uAje✓ _ -_ __— DATE %_-i — ' ' SI 444 10 e- t03o G. UN V1 O L T — 1#in Application Accepted By ` Date _/ E Area --t Y _ Employee ID# W009 1s Final Inspection By Dale g SPECIAL PERMIT-Approved by Character of Soil to ep h of t: __ Pit/Sump Soil Character: COMMEN"f S - l U IZ A414 ZJEW ftga ¢1' �e o r �t 41 I4 Mori t PE Sc Received Check#/ Amount Perm1U Code INFO EICash Re Date Service R uest# Invoice N Permit IDK os S 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5117