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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 EXPIR (E �S 1 EAR FROM DATE ISSUED rp JOB ADDRESS 2-L2)' �=� � t �k CITY/ZIP �� jN i�(�a �-1 n CROSS STREET �� APN y X11$0 l PARCELSIZE r� OWNERNAME OrY Y) 1�L / ,PHONE Z�� 410C q, ci itit(:)OWNERADDRES,lS,_ 3V(�U)o "tor e ��CITY/STATE/ZIP ( CONTRACTOR am yl �� IPHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑❑C-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ' ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT# P-v?IJ S LAND USE APPLICATION #_ TYPE OF WORK: ❑ NEW INSTALLATION >< REPAIR/ADDITION ❑ ENGINEER DE; 11REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION u GNED/ALTERNATIVE INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP _ CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS # OF LINES1l DISTANCE TO NEAREST WELL. ft FOUNDATION (7l ❑ FILTER BED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION ft FOUNDATION ft LENGTH OF LINEs �S� r L ft ft PROPERTY LINE ii�7 3 T ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LIN ft DEPTH ,�fli�_ ft ft PROPERTY LIlS� -�+ ft DEPTH ft ft PROPERT ft DEPTH HE�i �I. . COI_/�' �� ft ft PROPERTYLIN�pr,rl A� ft 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 5IGNED TITLE DATE ��iPJtli'� f7P'�FfY✓1P� /{AproY`E�11 1 PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO B Ca h Remitted Service Request Pe{ SievPn Sieh CYcc3f,�' ��- Prow) S�c�O$3SsS-vJ�iS 42-01 � �+ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT Olppl/eol}� fi6►Kpe3mi�•'• y 4/14/18 SI2a0�3sSS� h4�a FPP of 7/ ■■■■■■■■■■��I�rli��■■■■■■_■_■_�■��■I■■■M■�■■E■■■ # ■■■■■■■■■��■■■■■■tip■■■■■■■■■��(��II■■■F�■■■EANN W)r -1.1 Date 0 • f / / i ��iPJtli'� f7P'�FfY✓1P� /{AproY`E�11 1 PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO B Ca h Remitted Service Request Pe{ SievPn Sieh CYcc3f,�' ��- Prow) S�c�O$3SsS-vJ�iS 42-01 � �+ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT Olppl/eol}� fi6►Kpe3mi�•'• y 4/14/18 SI2a0�3sSS� h4�a FPP of 7/ # Sa.