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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN 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 J08 ADDRESS U - /C CITY53 �/yZI/P ClG K Ix, CROSS STREET c� / ^ APN / ) 1 1, l ' 0 �� PARCEL SIZE '� • �s'/ OWNER NAMEA�—� / L/ PHONE OWNER ADDRESS �7�41A/t. I i CITY/STATE/ZIP ` CONTRACTOR �r �'1f�Jr��li> `I�//JI/� J, Od _ �• .� PHONE q2 .// , 1T � CONTRACTOR ADDRESS �� i'1 .� L Yll/w .C� '1 CITY/STATE/ZIP ��'�i`��TL��/ �✓F. .i/ LICENSE ❑_C42 ❑_C-36 OTHER ,e_ NUMBER EXPIRATION DATE �i(. •J"� J,2.L� C�� WATER TABLE DEPTH: I L V ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # LENGTH OF LINES ft BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: _ NEW INSTALLATION EPMR/ADDMON ENGINEER DESIGNED /ALTERNATIVE ft FOUNDATION REPLACEMENT o -. OUT -OF -SERVICE SEPTIC SYSTEM _ DESTRUCTION INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER E—EEI NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: JQ SEPTICTANK TYPE/MFG j ,/ Of—<le CAPACITY / L� V gal # OF COMPARTMENTS !C'/ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS LENGTH DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) �Q LEACH LINES L LEACHING CHAMBERS # OF LINES _� LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO WELL ft FOUNDATION ft PROPERTY LI ft SUMPS /N)EAREST WIDTH i ft LEN T LT+ �/ ft DEPTH 7ft DISTANCE TO NEAREST WELL _�� l L L ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. COMMENTS PE Sc Receive Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO Cash RemittSe ice ReqLLeV # PAYMENT DECEIVED � EB 2 2 2021 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 rc-