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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 PERM <br />LL (209) 953-769/ FOR INSPECTIONS tXPIKLS l T LAK t-KUM UAI t I5JUt1 <br />JOB ADDRESS CITY/ZIP N \ G )v ) �jN Irl t2 <br />CROSS STREET ��� APN ! Cid 3 d a O 6 PARCEL SIZE 115 T- <br />OWNER NAME4�L V\ V� l��- PHONE <br />'S+' <br />OWNER ADDRESS `�J\ t� CITY/STATE/-Z-IIP�[�` <br />CONTRACTOR �J �� r��c ��� (��67 PHONE <br />CONTRACTOR ADDRESS ` \ r\� J� �7 CITY/STATE/ZIP <br />LICENSE <,—C-42 ❑ C-36 OTHER NUMBER77?— L- EXPIRATION DATE 03- 3 - Z3 <br />WATER TABLE DEPTH: _ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # J ,- U J q LAND USE APPLICATION # <br />TYPE OF WORK: X NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: IN. RESIDENCE <br />SC <br />INFO <br />❑ COMMERCIAL <br />❑ OTHER <br />Amount <br />Remitted <br />Date <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: L) <br />NUMBER OF EMPLOYEES: <br />yal <br />!17 <br />SEPTIC TANK <br />,cam <br />TYPE/MFG �tii�'� <br />�2 <br />CAPACITY �P <br />gal # OF COMPARTMENTS_ <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL `©C) It FOUNDATION I <br />i ,tom <br />ft PROPERTY LINE � \ yl <br />ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />n- <br />-I LEACHING CHAMBERS <br />- - - <br /># OF LINEs <br />- - - --- -- —. <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />FILTER BED <br />WIDTH -,� 2 ft <br />LENGTH <br />4,7-)` ft <br />DEPTH ala" <br />ft <br />DISTANCE TO NEAREST WELL <br />k <br />+[� t <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■!�■J`:iii■■■■■■■■■■■■■■■■■■�!!i�,�r�i��}'_�?!�i <br />• r - . ■ •• • • • <br />• <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />heck <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />yal <br />!17 <br />s <br />I. q 2Z <br />s 0Ogy1-1-0C7 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />