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i <br />IS <br />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 209 953-7697 FOR INSPECTIONSEXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ' e- f�'- CIICITY/ZIP'r5C G% Z L�1 <br />CROSS STREET S E �/ F" 7 V /� �✓i A P N A % �r�' `' � 3 PARCEL SIZE <br />OWNER NAME <br />Jae a ��C� PHONE; 'G� f <br />OWNER ADDRESS :•-1� .�' C/.jf- _ _f,� CITY/STATE/ZIP <br />CONTRACTOR 15;:i'^ p <br />PHONE <br />CONTRACTOR ADDRESS <br />LICENSE ❑GC -42 110CC-36 OTHER NUMBER <br />CITY/STATE/ZIP <br />EXPIRATION DATE <br />Invoice # Permit ID# <br />WATER TABLE DEPTH: / (o ft GEOGRAPHICAL INFORMATION: <br />COordlnates X Y <br />❑ PERC TEST # BUILDING PERMIT # <br />5r-?—,)�-VW96 LAND USE APPLICATION # <br />TYPE OF WORK: ' NEW INSTALLATION <br />REPAIR/ADDITION I I ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT G <br />OUT -OF -SERVICE SEP TEM I DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL❑ OTHER <br />W <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />% <br />SEPTIC TANK TYPE/MFG 4»! V <br />CAPACITY OD gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL S TOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES ❑ LEACHING CHAMBERS <br /># OF LINES LEN OF LINES <br />ft <br />DISTANCE TO NEAREST WELL 1Q(� <br />ft FOUNDAT10N _ft PROPERTY LINE <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft <br />ft DEPTH <br />ft <br />yLENGTH <br />DISTANCE TO hlEArT3 <br />ftt,�FOUNDATION ft PROPERTY LINE <br />ft <br />If SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO EAREST WELL ft FOUNDATION D ft PROPERTY LINE <br />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 />VIN /I\Jr LV i IVI11J - VLL " V/7L1_ ILVJ/ JJJ-I VJI <br />TITLE Q'1//!�� DATE �Lr 'oZ0 <br />PE SC Received Check# Amount <br />Date Permit/ <br />Invoice # Permit ID# <br />Code INFO By ash Remitted <br />Service Request # <br />zA <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />rj <br />Y <br />C <br />C <br />z <br />n <br />K, <br />