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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-KEFUNDABLE PERMITGALL ZUY 953-/b9/ FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS <br />``11 <br />V <br />-, . r L <br />CITY/ZIP, <br />Permit/ <br />Service Request # <br />CROSS STREET <br />A <br />/ V O rl b'aA 17 d APN i � !J� <br />� V � <br />PARCEL SIZE <br />OWNER NAME <br />1' ���1 ��� �0G-c <br />3 <br />PHONE <br />OWNER ADDRESS <br />/ �n%n //��v� ������ C ✓`� - CITY/STATE/ZIP <br />CJ ^-G �� <br />CONTRACTOR <br />pCF <br />/=/%I��Q / e �`�r �- 4' e� <br />PHONE(� <br />_1 <br />CONTRACTOR ADDRESS % �' /yJ/�J (/ C t % �' <br />CITY/STATE/ZIP <br />CAPACITY <br />LICENSE ❑ C-42 <br />❑ C-36 OTHER )7 NUMBER -�)( -f <br />EXPIRATION DATE <br />ft FOUNDATION ? V <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/AD <br />Coordinates X Y <br />LAND USE APPLICATION # <br />' • IN ENGINEER DESIGNED <br />REPLACEMENT f4jjK Y tl i OUT -OF -SERVICE SEPTIC SYSTEM -r- DESTRUCTION i6f <br />TERNATIVE <br />INSTALLATION WILL SERVE: <br />RESIDENCE ❑ <br />COMMERCIAL <br />❑ OTHER <br /># OF LINES <br />Permit/ <br />Service Request # <br />LENGTH OF LINES <br />ft <br />L)aIL <br />DISTANCE TO NEAREST WELL <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />3 <br />NUMBER OF EMPLOYEES: <br />O <br />SEPTIC TANK TYPE/MFG <br />CJ ^-G �� <br />CAPACITY U `� <br />gal # OF COMPARTMENTS 2- <br />❑ <br />GREASE TRAP TYPE/MFG <br />ft <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL J J <br />ft FOUNDATION ? V <br />ft PROPERTY LINE <br />❑ <br />LIFT STATION SIZE <br />TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br />t iuwwwcnr-.vim► icnnr�_n»v_r�I4.t/ • - <br />Amount <br />Remitted <br /># OF LINES <br />Permit/ <br />Service Request # <br />LENGTH OF LINES <br />ft <br />L)aIL <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />I� FILTER BED <br />WIDTH ft <br />LENGTH <br />S (r- 3C <br />ft <br />DEPTH <br />�f't1 <br />UOt;nIF� ii <br />DISTANCE TO NEAREST WELL <br />% 0 <br />ft <br />FOUNDATION <br />—e <br />ft PROPERTY LINE z ft <br />❑ MOUNDED <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />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 />PE <br />Code <br />SC <br />INFO <br />t iuwwwcnr-.vim► icnnr�_n»v_r�I4.t/ • - <br />Amount <br />Remitted <br />Dat <br />Permit/ <br />Service Request # <br />Invoice # <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■m■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■"■■■■■■■■■■■ <br />L)aIL <br />)Is- <br />31Z <br />•Ell <br />PE <br />Code <br />SC <br />INFO <br />Receivedhec / <br />By Cash <br />Amount <br />Remitted <br />Dat <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />L)aIL <br />)Is- <br />31Z <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14118 <br />