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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 PERMIN CALL ZU9 953-/b9/ FOR INSPECTIONS txNIKt5 -1 TEAK I-KUM UA It ISSUtl JOB ADDRESS '7 . C� `� �✓�� d ' �CCITYI`ZIP -7l'4 L ) i t C 5-r309 CROSS STREET �h-° '�— APN Z �Ci /UJ� PARCEL SIZE 1, V OWNER NAME V 1 t ':S7 \r\. OSI VG l \ PHONE OWNER ADDRESS C `/ V� CITY/STATE/ZIP DG -7 CONTRACTOR�/ l C+ /G al nQ PHONE-,-,-, 7�c�� 2 ��L 3 CONTRACTOR ADDRESS Z/3) �`CWZ^'� � ' — (0a"-� CITY/STATEIZIP LICENSE EIIC-42 ❑ 9 b IC -36 OTHER NUMBER /� j! ? EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION :5 r) INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES I- LEACHING CHAMBERS Received By Check ash # OF LINES Date LENGTH OF LINES Invoice # DISTANCE TO NEAREST WELL 075' ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ............................................ &dl ft ft ft ft ft ft ft ft ft ft ft ft PE Code SC INFO Received By Check ash Amount Remitted Date Permit] Service Request # Invoice # Permit ID# ) 075' to '20 12.00 aZS 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18