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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P✓' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVUN-ISthUNUAt$Lt rtHMI 1 CALL ZU9 953-7697 FOR INSPECTIONS �/� /�E�pXPIRES 1 YEAR FROM DATE ISSU JOB ADDRESS 10 �A�� /a CITY/ZIP Ll L U'T w1 s,3-?[) CROSS STREET �`e�V��('� ' 4 't"t2L /F--4 APN° ( O — O� �I('�ARCEL SIZE 1t7WNER NAME �/V11��✓amu l c��L9 �/ ICfi� J ,n / Ck—O�E �Z IrOWNER ADDRESS l /� ' �-'/-1 l� / ��i/ ITY/STATE/ZIHI CONTRACTOR ^�]` Vi^"'�/1`c� 1�d�t, (�J� _ _ PHONE �✓ 1 �� ` I �� CONTRACTOR ADDRESS // -w� �J� CITY/STATE/ZIP 1�VtZ IV CA S�� A LICENSE I I C-42 I I C-36 OTHER NUMBER CLO EXPIRATION DATE t I WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y CI PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNA REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ❑ LEACH LINES LEACHING CHAMBERS DISTANCE TO NEAREST ❑ FILTER BED WIDTH (OISTANCE TO NEAREST ❑ MOUNDE WIDTH `"r Y*Y b ✓✓✓✓✓✓ b'®>CE TO NEAREST DT ❑ !." � H i�. ` DISTANCE TO NEAREST ❑ Qr§0z OND$ WIDTH DISTANCE TO NEAREST ❑ SEEPAGE PITS NUMBER DISTANCE TO NEAREST WELL ft LENGTH WELL ft LENGTH WELL ft LENGTH WELL ft LENGTH WELL WELL WIDTH CAPACITY gal CAPACITY gal ft FOUNDATION ft ❑ PKG TX PLANT ❑ SAND OIL 7 # OF COMPARTMENTS # OF COMPARTMENTS }} PROPE mr7 ]L-� ft # OF LINES LENGTH OF LINES ` jlY 14'0"k ft ft FOUNDA1k0N ft FOUNDATION ft FOUNDATION ft FOUNDATION ft FOUNDATION ft FOUNDATION ft PROPERTY LINE It ft DEPTH ft ft PROPERTY LINE ft DEPTH 'tt ft PROPERTY LINE t ft DEPTH JUN 0 7a, ft ft PROPERTY LIM1!£/V rullff ft ft DEPTH .9 NV�.IN �,ft ft PROPERTY LINE`/HDEPryAa� AA ft ft DEPTH �.•IL�T ft 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. MIN UM eHOUR ADVANCE NOTICE REQUIRED SIGNED - C/ Application Accepted Br,\4Vt Uk Final Inspection By Character of Soil to Depth of'S"Ft: COMMENTS - PLEASE CAL TITL DATE DEPARTME N ToeV S�ONLLY DateCF _ AreaEmployee ID# _ Date_ _ ElSPE"PERMIApproved by Pit/Sump Soil Character: PE SC Received Amount Permit/Code INFO B Ga ash Remitted ate Service Request # In F, A41 ► ID# o 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17