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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 GALL ZUbl ybJ-/6y/ FOR INSPECTIONS MAI'IKtb I T tAK r*KUm vA I t Iwaurl <br />JOB ADDRESS 1 C G^��c� 1�G CITY/ZIP/��-2i^ J 2,1� <br />CROSS STREET N i C MjOI� { APN PARCEL SIZE �` y <br />OWNER NAME —5A—lV t---, PHONE <br />OWNER ADDRESS �� Ci--�.s�I� j+ �i (1 r CITY/STATE/ZIP <br />CONTRACTOR �4,1 /-- r� i.t �Q v —' PHONE <br />CONTRACTOR ADDRESS G.� ��✓„ -'-.j` _ CITY/STATE/ZIP <br />LICENSE ❑CIC -42 ❑CIC -36 OTHER_�1� NUMBER /-T�/j, EXPIRATION DATE <br />WATER TABLE DEPTH: 1 CO ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION I I ENGINEER DESIGNED /ALTERNATIVE <br />Li REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM IJ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP, <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />f' LEACHING CHAMBERS/ <br />L <br /># OF LINES <br />LENGTH OF LINES 4 0 <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />SJ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH --- <br />'7S <br />DISTANCE TO NEAREST <br />WELL ft S J ft <br />FOUNDATION PROPERTY LINE �. <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 />PE Sc Received Check#/ Amount Date Permit/ Invoice # Permit ID# <br />Code INFOCash Remitted Service Request # <br />47-1 l )�L <br />.)I I za15jwA191px <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />