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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-$420 <br />NON-KEFUNDABLEPERMIT <br />(;ALL LUY YY03-16!11 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS [` (2Q L r <br />/• <br />y �y�,L �n <br />CITY/ZIP( <br />J�VI.CA.�st�dj� <br />1~•l'� `S2 �6 <br />CROSS STREET . }fi, <br />APN <br />p � 09 aa6 <br />PARCEL SIZE 3 `, qy <br />OWNER NAME D W 9 <br />6coefSm G1 It L P <br />+30a <br />PHONE <br />OWNER ADDRESS I � Oda <br />C,q 0C' Dr. <br />y�/► <br />CITY/STATE/ZIP MelPd <br />(/�1 <br />CCe- <br />f <br />CONTRACTOR 11 � iLSL16 ,S <br />aG��k b -G Ste% � <br />PHONE u. <br />^ <br />� d-�G , <br />CONTRACTOR ADDRESS <br />// <br />RI (? S�Ci <br />CITY/STATE/ZIPa <br />c��} R C36: <br />LICENSE ❑I C-42 ❑ C-36 <br />OTHER NUMBER <br />EXPIRATION DATE <br />� <br />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 ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -0F -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: pjRESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 41 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION _ <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />EACH LINES <br />LEACHING CHAMBERS <br />ReceivedCh <br />By <br /># OF LINES I <br />LENGTH OF LINES go I ft <br />Date <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION 11:5 1 <br />ft PROPERTY LINE 16� ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />+30a <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />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 />• • • • .�n'L9yClIll1 y.••tvi..r,i.rnr-►�ii►•nnrn�cn-�_r�I4.F/ . - <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■;�■■■■ <br />■■■■■■■■■■■■■■■■`1/!■■■■■ren■Il■■■■■■■E�1■fY�1■�■ <br />■■■■■■■■■■■■■■■■i■■■■i■■f iii�i!:�■Ili;■■IAC go Mi02A <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />1 ! M �. <br />PE <br />SC <br />INFO <br />ReceivedCh <br />By <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit III <br />y1310 <br />Its' <br />l <br />+30a <br />lo -lo -ZZ <br />SQ�,�Le <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />rr <br />