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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS a 41 L M� CITY/ZIP_ O k c6 l eq6,36/ CROSS STREET 'V11 in APN _ 2-0 Z 90 1 't /JPARRCEL SIZE p�. (yy� OWNER NAME Q �u' , _ ` _ PHONE �+�� • b �� 6�QiC �( OWNER ADDRESS ZC1 OL-{ I � A'Q, _ . _CITY/STATE/ZIP a_c� �, 4 A AS -- CONTRACTOR PHONE CONTRACTOR ADDRESS LICENSE I_)i C-42 ❑' IC -36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION DATE_ .- WATER TABLE DEPTH: L L --a ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT #%i7t'_)�71_ANDI USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM Y ENGINEER DESIGNED /ALTERNATIVE DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL 1 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 Y2 0 DISTANCE TO NEAREST: WELL ft FOUNDATION It 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 /L TITLE_DATE rnD-o xUT X ADO I- EXISTING SEPTIC y =o O B ] r rn r H Ln 150' -0' VERIFY G)Zrq LES ° ul in rn W --I z i i OO l� TX o Wer L^ z z (7 0 CIL W DRIVEWAY < N rnC� 1�, , , .. - .. • • ' • 883.90' ' • 1 EPA RTI!4FJVT USE ONI.Y Application Accepted By' _ Date_ �'�� 7 Area l y.� Employee ID# Ski„ Final Irspection By_ Date_ Z__7J!'"z/-- I 1 SPE�IA�L E5MIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character:.SCt Q COMMENTS '��j - u` PE LEACH LINES FI LEACHING CHAMBERS Check#/ Amount Cash Remitted # OF LINES Permit/Code Service Request # LENGTH OF LINES Lf C2 It Permit ID# Y2 0 DISTANCE TO NEAREST WELL �O _ It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft SUMPS WIDTH ✓^ It LENGTH ft DEPTHF4 10 ft DISTANCE TO NEAREST WELL It FOUNDATION t� ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER _ WIDTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It 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 /L TITLE_DATE rnD-o xUT X ADO I- EXISTING SEPTIC y =o O B ] r rn r H Ln 150' -0' VERIFY G)Zrq LES ° ul in rn W --I z i i OO l� TX o Wer L^ z z (7 0 CIL W DRIVEWAY < N rnC� 1�, , , .. - .. • • ' • 883.90' ' • 1 EPA RTI!4FJVT USE ONI.Y Application Accepted By' _ Date_ �'�� 7 Area l y.� Employee ID# Ski„ Final Irspection By_ Date_ Z__7J!'"z/-- I 1 SPE�IA�L E5MIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character:.SCt Q COMMENTS '��j - u` PE SC INFO Received B Check#/ Amount Cash Remitted Date Permit/Code Service Request # Invoice # Permit ID# Y2 0 adz 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17