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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 �(I.� (LU`JJ `J53-y/b`J�/ FOR INSPECTIONS A' y,CX�YIHtS IQTtwH FHVM uwlt L`iCiUtl JOB ADDRESS I CITY/ZIP eLL'.-.l /1 A4 c) ISZZ� �j CROSS STREET 1�T11 ►'` /y T APN a _ �, ` 'I"'� PARCEL SIZE OWNER NAME /'� rNpVL�^'��,/ ,Q VQ(� OZ- ,y, PHONE / (� OWNER ADDRESS 447,1+4 T4 /z m 5;it ^� �t4i L �p CITY/STATE/ZIP�7 q��77b" C 1 41r �� CONTRACTOR LIVE cAY— .. I&EC�E �vjv IIoNm E�' A` PHONE 7IO I `oil Ste}{ �j ,.1 CONTRACTOR ADDRESS 40 1 ✓� + O l < r ST. CITY/STATE/LIP Lit) t —' • �2W TC1 LICENSE E..C-42 ❑ i:.;C-36 OTHER C E U NUMBER ( EXPIRATION DATE � f so WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOrdlnateS X Y PERC TEST # I BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION .. REPAIR/ADDITION ISI ENGINEER DESIGNED/ALTERNATIVE .... REPLACEMENT .... OUT -OF -SERVICE SEPTIC SYSTEM I'.i DESTRUCTION INSTALLATION WILL SERVE: PREPARED THIS _ RESIDENCE IN ACCORDANCE WITH J COMMERCIAL PermiU Service Re uest# L OTHER LAWS AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY. 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 ft PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH it DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, PermiU Service Re uest# STATE LAWS AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY. IV/IIV/IVIO CILIUMNIYIiC IPV IIl/C I"iC {/Irt G1J rVll IIYJt-C li 1IVIYJ - rLCMJC VMLL LVJ JJJ-/V�/ SIGNED TITLE PQ'y � ' ►'�62 • DATE � �' `� _ 7�0 PE Code SC INFO Received B eck# Cash Amount Remitted Date PermiU Service Re uest# Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18