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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-T697 FOR INSPECTIONS t EXPIRES I YEAR FROM DATE ISSUED <br />�7 /'I <br />JOB ADDRESS ' I;ITY I IP . �' I .m c, ,/ �/ I <br />CROSS STREET <br />A_PIN 1--6I <br />`i L Ko I� <br />PARCEL SIZE I <br />OWNER NAMEL 4, <br />I CGT �CV C;, <br />PHONE <br />OWNER ADDRESS <br />CITY/STATEIZIP// <br />CONTRACTOR I �2 <br />C T <br />.lX 1 <br />PHONE <br />FriII <br />CONTRACTOR ADDRESS r7J6 <br />Gs� <br />LICENSE ❑�C-42 [17C-36 OTHER <br />y9 .1 <br />NUMBER �JPPIRATION <br />(CITY/STATE/ZIP <br />DATE <br />C � <br />WATER TABLE DEPTH: �� ft GEOGRAPHICAL INFORM{VTMN- 1 COONinateS X Y <br />❑ PERC TEST #BUILDING PERMIT # _ 2od'I 4( LAND USE APPLICATION #-1 F_ <br />TYPE OF WORK:W RV INSTALLATION �! REPAIRIADDITION EER UESIGNcc�E�D IA TERNATIVE <br />REPLACEMENT _ OUT-OF-SESEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: Q-11FESIDENCE ❑ CO ERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: /1 NUMBER OF BEDRO S: )) / NUMBER OF EMPLOYEES: <br />9 --SEPTIC TANK TYPE/MFG DV L L r3L3 gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL % /1I_ ft FOUNDATION ft PROPERTY LINE L7 /� J t ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED <br />// SYSTEM) <br />W-TLEACH LINES ❑ LEACHING CHAMBERS # OF LINES �� LENGTH OF LINES r ft <br />DISTANCE TO NEAREST WELL1�✓'� ft FOUNDATION Z'.i ft PROPERTY LINE ft <br />❑ FILTERBED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL Q J ft FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER WIDTH L4 ft DEPTH, 1 ft <br />i <br />DISTANCE TO NEAREST WELL / C rj ' ft FOUNDATION , Q�� ft PROPERTY LINE a4i ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />IV/lnll/Y/V1Y/ 4Q AV I[ VHI IYVI/l.0 RG V/RG✓ rVR 1111JrCV I /VIYJMM' ,r�,,LGHJC LVJ JJJ-/V,j/� <br />SIGNED TITLE 1* 'A^ C DATE ..-I gul{['� <br />PAYMENT <br />;ECEIVED <br />EB 2 6 2021 <br />JOAQUIN COUNTY <br />WRONMENTAL <br />LTH DEPARTMENT <br />4/14/18 <br />Stip <br />