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PERMIT <br />EXPIREI�NSITE WASTEWATER TREATMENT SYSTEM PERMIT�P���E///nR ^MIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA `JSL(F�- (�p'{3420 <br />11 n_ <br />•� ��.�tio�� rtnnn I (:AL Z09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] <br />JOB ADDRESS IffID IF a s llis /- CITY/zZIP / /1l� Vi0 (SZ a <br />q r <br />CROSS STREET 19 fro y� ' 11�j APN _ f <br />Kor%(tin ben�2�r Ur PARCEL SI <br />ZE / <br />OWNER NAME Q1 PHONE/�1 <br />/ (ML 1 �`I�•��%) 1n) I <br />OWNER ADDRESS 1 ula5h to K- CITY/STATE/ZIP <br />CONTRACTOR Db l Qpar y S�CIVIIZ'i PHONE 2N- I�A- <br />CONTRACTOR ADDRESS O-I/l' I� I I Qj�w S� 'n^ Q CITY/STATE/ZIP W 1i l 0 I (p <br />LICENSE ❑❑C-42 ❑❑C-36 OTHER 1' NUMBER �/ l� O EXPIRATIONDATE \01,3117-0 <br />U <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION ## <br />TYPE OF WORK: 17 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED A/L; RNATI E <br />E]A <br />REPLACEMENT L1 OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION l <br />INSTALLATION WILL SERVE: El RESIDENCE 11 COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />GREASE TRAP TYPE/MFG _ .oncu _ CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL FOUNDATION ft PROPERTY LINE ft <br />LIFT STATION SIZE TYPE OF PUMPt`Act ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />- G Z _n <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />ft ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL _ <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />V(Piper) <br />ft <br />DEPTH <br />, <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />El sumps <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LIN <br />ft <br />El DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />✓O <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATIONft <br />PROPERTY LI <br />IR CO ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ENTft <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 />SIGNED <br />�1IVIYJ -- <br />209 953-7697 <br />DATE L 40 3"' C/ <br />PE SC Received C Amount Date Permit/ Invoice # Permit ID# <br />Code INFO !3y, as Remitted Service Request # <br />--'590M 70.E PE IT <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />PERMIT <br />IRED <br />f <br />