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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE VEERMMIT GALL 1U9 953-7697 FOR INSPECTIONS EXPIRES. 1`YEAR FROM DATE ISSUE JOB ADDRESS - (i' b /I CITY/ZIP '/' G !i / J % W; l CROSS STREET �'" ; A0L( r Am —e -/ )/ APN � S 5 3 � � � � PARCEL SIZE �� S / OWNER NAMEsZ/w h P_ PHONE OWNER ADDRESS 3GO 6/' ,7 �, �) j /^ CITY/STATE/ZIP Tra G vl. /2,2R CONTRACTOR ' 4 Q/e� q� PHONE 1 j,2R CONTRACTOR ADDRESS p C/ / 'p 'e/y36/'6/'EXPIRATION f CITY/STATE/ZIP LICENSE (�-42 ❑ C-36 OTHER NUMBER U /y/2 6-'G//' EXPIRATION DATE WATER TABLE DEPTH: O� ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # a? 10,3 001 LAND USE APPLICATION # TYPE OF WORK: ( NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT ! OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER / NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: [y SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL , cc) SIZE TYPE OF PUMP ft ft CAPACITY 42--a O gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS FOUNDATION S ft PROPERTY LINE la ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS ■■frau■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Permit ID# # OF LINES LENGTH OF LINES 4/ C / ft DISTANCE TO NEAREST � WELL 12-0 ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. ' • 'i7.1/l•1•/\�I •I%I\'lel y\'lI/\•fy\t 4.' (4.N/ - / - SC INFO Received Check#/ Cash Amount Remitted ate Permit/ Service Request # ■■frau■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Permit ID# ya>> 117 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 00' PE Code SC INFO Received Check#/ Cash Amount Remitted ate Permit/ Service Request # Invoice # Permit ID# ya>> 117 U1sS 00' 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18