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I <br />I <br />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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS (/�� r j �f/�G G c,n P R� �J CITY/ZIP C -= -%'g <br />CROSS STREET JL 1 { , C UV G) Y APN � 'T�� ! �_ PARCEL SIZE <br />OWNER NAME r� PHONE <br />OWNER ADDRESS I CITY/STATE/ZIP <br />CONTRACTOR 0Y ( S /[�f 4 U� \ 'L 2� f PHONE_ e tiM- p L S- r <br />CONTRACTOR ADDRESS IK� ✓dC>>C t e t J CITY/STATE/ZIP <br />LICENSE 11LIC-42 11oC-36 OTHER NUMBER (p EXPIRAT0NDATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 1 VIEW INSTALLATION - REPAIR/ADDITION 11 ENGINEER DESIGNED /ALTERNATIVE <br />W REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION .. i <br />INSTALLATION WILL SERVE: VESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />0 SEPTIC TANK <br />TYPE/MFG j2t-A- <br />CAPACITY I_ Y 6b <br />981 <br /># OF COMPARTMENTS .L <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />ft DEPTH ft <br />DISTANCE TO NEAREST: WELL, <br />ft FOUNDATION �tS I <br />ft <br />PROPERTY LINE �� ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Ebl--LEACH LINES <br />L LEACHING CHAMBERS <br /># OF LINESI <br />LENGTH OF LINES � ft <br />Permit/ Invoice # Permit ID# <br />DISTANCE TO NEAREST <br />WELL , D-0 I ft <br />FOUNDATION , ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />lR- SUMPS <br />WIDTH �)- ft LENGTH j a <br />ft DEPTH (oI ft <br />DISTANCE TO NEAREST <br />WELL T ISS ft <br />FOUNDATION j ft PROPERTY LINE �01 ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <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 />VIS 11\JrLV / IV/tJ - rLL/'7JL V/'7LL ILVA/ AJJ-/ VJ/ <br />TITLE G C- �4 (� DATE 4 14 7 �- <br />PE SC Received Check#/ <br />Amount <br />Date <br />Permit/ Invoice # Permit ID# <br />Code INFO B Cash <br />Remitted <br />Service Request # <br />(2 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />Com. <br />m <br />Y <br />v <br />v <br />X <br />K <br />