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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT F/ -'� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT (:ALL Z09 953-7697 FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS C-1 2—IV [M -E 4QA -7CITY/ZIrP,'l, L �K no"^ 't C� 3 CROSS STREET C� P P�f°Y��1 -o-S 9) APN 0-5 -77A -- Y PARCEL SIZE OWNER NAME S yam! � =L, � -a n �1 _ r PHONE 'OWNER ADDRESS b IL AS's 1 `��• � O / &l0O TI b)Ck�- CITY%TATE/ZIP L-Zr'0e-'-'"N'�C? CONTRACTOR 41t k 1-/� I" PHONE 2-11"L - 'L10 1-78-L t e� CONTRACTOR ADDRESS Po (Sor j L3 , CITY/STATE/ZIP r 4 7 LICENSE ❑ C-42 ❑N-36 OTHER NUMBER 111(34` EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: ❑ PERC TEST # r BUILDING PERMIT # C TYPE OF WORK: PC NEW INSTALLATION I i REPAifi/AD1 tes X Y_ LAND USE APPLICATION # ENGINEER DESIGNED ❑ REPLACEMENT I I OUT-OF-SERVICE,EPTIC SYST EM DE51 HUG I ION INSTALLATION WILL SERVE: RESIDENCE U COMMERCIAL Ll OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: TERNATIVE SEPTIC TANK TYPE/MFG 1 0 P ' L CAPACITY 1 vim' gal # OF COMPARTMENTS 2— ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS 1 DISTANCE TO NEAREST: WELL , U f ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE _ TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED 'f/ TITLE C�t/r�G'— _ DATE 2— Application Application Accepted By� Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS DEPARTMENT U E ONLY Date T Area Employee ID# 2'� Date _d�b / 7 ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: S aw�e PE Code SC INFO Received B Che ash Amount Remitted Date f LEACH LINES ❑ LEACHING CHAMBERS _ # OF LINES_ LENGTH OF LINES ft V* DISTANCE TO NEAREST WELL it FOUNDATION ! �f ft PROPERTY LINE S f -� ft ❑ FILTER BED WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ------ It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft SEEPAGE PITS NUMBER1 � WIDTH ft DEPTH Z ft DISTANCE TO NEAREST WELL_ ft FOUNDATION I3' 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED 'f/ TITLE C�t/r�G'— _ DATE 2— Application Application Accepted By� Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS DEPARTMENT U E ONLY Date T Area Employee ID# 2'� Date _d�b / 7 ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: S aw�e PE Code SC INFO Received B Che ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# V* 7 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17