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t ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-t1EFUNUAbLE F`hHMI I yy,�}- L AJLL (ZU`JJ `J0J-/o`J/ FOR INSPECTIONS tXPIIHFS 7 YEAR FROM DATE ISSUE JOBADDRESS 111e7—Z E- 7pT1&f-AJE) W CITY/zIIP L—c> ISZ4y ? �1 CROSS STREET it( P713%y 1�) APN 0(93 - Z`fA _O I `P'ARCEL SIZE .J. 1 Z At. OWNER NAME "J 0 y /�% t!!J EZ.. PHONE A40 t C) -)R OWNER ADDRESS SAE may, r, //�� CITY/STATE/ZIP CONTRACTOR Lt t/ E 9f - Jy( t—ON "I vC7^ L PHONE 3 m l - 01-1 CONTRACTOR ADDRESS 14 01 w- C, A-V-- 9T- CITY/STATE/ZIP L -0't>11 LICENSE C-42 '_: C-36 OTHER CC& NUMBER Z15( EXPIRATION DATE T_3J-ZZ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ',K PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: _' RESIDENCE D COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY 981 # 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 ❑ FILTER BED WIDTH ft LENGTH It DEPTH I DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH I � DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTHSAN./if(, DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE l�. E3DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH CTinQ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It 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. SIGNED n irv�prc TITLE / ;U J m G -#e' ' DATE PE SC Received ec Amount Date Permit/ Invoice# PermitID# Code INFO By sh Remitted Service Request # 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 14 ?0�2 ME ouNTy