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ao-7yg1 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 <br />(:ALL <br />ZUY) 903-115Y[ FOR INSPECTIONS <br />tXPIIREnS I TEAR FROM DATE ISSUEI <br />JOB ADDRESS �4 Liq <br />T <br />J a4<�D /fie- <br />CITY/ZIP YC. <br />O� ! `►7 <br />CROSS STREET <jt' h 6DAy�/j1- <br />DISTANCE To NEAREST WELL <br />APIN a a �a �� a <br />PARCEL SIZE <br />Ia�,llett <br />DISTANCE To NEAREST WELL <br />ft FOUNDATIONROP <br />Ll DISPOSAL PONDS WIDTH ft LENGTH <br />OWNER NAME <br />/"1C�L1G� 3 J•,L`� <br />ft FOUNDATIONROP <br />PHONE <br />OWNER ADDRESS do 99-f-q�QL�� <br />ne <br />CITY/STATE/ZIP <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />CONTRACTOR Y" .IIG�GS <br />U�k0e— <br />I,/ 1 PHONE (E(, <br />Q <br />DATEi61 <br />CONTRACTOR ADDRESS PoX <br />(� <br />CITY/STATE/ZIP <br />p <br />Y/�1�gt7R'�� f1- / c�'9 LS Su <br />L1.LICENSE . C-42 ❑'iC-36 <br />OTHER -4-- �^ NUMBER / <br />EXPIRATION DATE go.) -a/ 1 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION i ENGINEER DESIGNED /t LTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM �-�DESTRUCTION • eAA L <br />INSTALLATION WILL SERVE: 7'RfSIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG pd -L- CAPACITY t )� 15 1c. gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL 56� ft FOUNDATION 16 i ft PROPERTY LINE Yj}/ ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />■ LEACH LINES LEACHING CHAMBERS <br /># OF OF <br />DISTANCE To NEAREST WELL <br />ft FOUNDATION ft PROPERTY <br />■ • •ft LENGTH <br />g q ft DEPTHtell <br />DISTANCE ToFOUNDATIONPROPERTY <br />■ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE To NEAREST WELL <br />ft FOUNDATIONPROPERTY <br />Lj SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE To NEAREST WELL <br />ft FOUNDATIONROP <br />Ll DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE To NEAREST WELL <br />ft FOUNDATIONROP <br />L2 SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />DISTANCE To NEAREST WELL <br />ft FOUNDATIONROP <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 • RULES AND REGULATIONS OF •••COUNTY. <br />MINIMUM 48 HOUR ADVANCE NOTICE• <br />•' INSPECTIONS - PLEASE CALL (209)• .• <br />SIGNED /i_ <br />DATEi61 <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />1111 0 -one <br />• /r. <br />=. <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Lid <br />115- <br />3a� <br />22 <br />5 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />rA <br />