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f z 1 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE PERMIT JOB ADDRESS CROSS STREET ( I OWNER NAME OWNER ADDRESS U v CONTRACTOR LAA CONTRACTOR ADDRESS I -I n V V LICENSE *42 111113-36 OTHER GALL LE Y C7l ` •_ �r 9 9bJ-/697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED i CITY/ZIP `�7 �C 2Li S APN I 7 _ ( LyIJ 6) PARCEL SIZE) PHONE .,�I `IZlY7 I "1 r CITY/STATE/ZIP C-��i��/ q's- Z PHONE (/ -5 , O (i7 7 1 j to J41 C&: CITY/STATE/ZIP GO �l�Z g NUMBER EXPIRATION DA WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION D ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT BOUT -OF -SERVICE SEPTIC SYSTEM L DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NLIBER OF BEDROOMS: NUMBER OF EMPLOYEES: LINES r Received /ItIfeckor Amount ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS FOUNDATION4gf) ft PROPERTY LINE DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LINES ❑ LEACHING CHAMBERS Received /ItIfeckor Amount Date Permit/ Invoice # Permit ID# # OF LINES LENGTH OF LINES ft /LEACH DISTANCE TO NEAREST WELL Service Request # ft FOUNDATION4gf) ft PROPERTY LINE �� ft ❑ FILTER BED WIDTH ft L NGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NE REST WELL ft FOUND TION ft PROPERTY LINE ft Cyd SUMPS WIDTH ft LENGTH ft DEPTHS ft DISTANCE TO NEAREST WELLft FOUNDATION • [ ft PROPERTY LINE y ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 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. IY11111Y IYI UIY/ 4 url 14u V/•1/YI.0 /YV IIL'c RC V11[CL r-Vr[ 11YJrC%,I fulvJ - r-I-C/iJC IiFILL I AVJ auo-/ a SIGNED Com" `Ti /��GL7iu TITLE iu'�CS� DATE PE Sc Received /ItIfeckor Amount Date Permit/ Invoice # Permit ID# Code INFO B Remitted Service Request # 13W 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18