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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P v"- � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT / IC'ALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Z D7 / L-6. I 1 u e. 1 y )q'D �f �J ___ CITY/ZIP ��{ 1 D '95-3 �C4 CROSS STREET I E O f N 1-7 ,�Q 3 Z �D PARCEL SIZE 4-4 AC OWNER NAME _ � S ��' 1 � [ i�t'��/1G / G "w�I G(U r PH ON ZO-7/�� '7 4,q�` OWNER ADDRESS 18 0 , ll_ �'/ /� 7��/v K/�/S T CITY/STATE/ZIP 1 � LLQ ✓ ✓ LP 4e CONTRACTOR• a�e7�.��!"1�.i.�l PHONE_ CONTRACTOR ADDRESS 731,2�y�,]l _%CITY/STATE/ZIP__ LICENSE C-42 C-36 OTHER c-4 7---�+� •{ - / NUMBER I1 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 N DESTRUCTION %�N r1 INSTALLATION WILL SERVE: I RESIDENCE I COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG _ CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ftPROP ft L3 LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR ) _ ..-...._..._ _ _ ................ _.......... _..__.-.___.__ _._v__.. _- . _._ ____,. _.._._._.. _... ............... PTR❑ LEACeE ACHING CHAMBERS # OF LINES LENGTH OF LINES ft V ISTANO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FIjl16TF� ftLENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY-� INF _ ft ❑ MOUNd WIDTH ft LENGTH ft DEPTH V_ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH _ _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER)WE A2018ft ❑ DISPOSAL PONDS WIDTH _ ft LENGTH ft DEPTH __ ft CO DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPEFCT c/�n AQUfi1I"•iUNTY ft ❑ SEEPAGE PITS NUMBER WIDTH _ ft DEPTH "EAL�T�1H1+D�E�P�AR�TMAENT ft DISTANCE To NEAREST WELL ft FOUNDATION 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.2nQUa ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE At7� tJ r DATE 5� Application Accepted By/ k V1x , /(4111-l_ Date` S _q-1 I Area Employee ID# A" m' Final Inspection By Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: _ Pit/Sump Soil Character: COMMENTS /) u UV)ret -4a r1 t'Wc, U 11j,bde hc,-,,7<' PE Code SC INFO _.... ... _...... ....... Received B ec Amount Remitted Date Permit/it Service Request # ID# 1 c? 5 021 - as-fibEAPTIlym 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T to Y v v M