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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 NUN-1111:11UNDABLE VERMIT (:ALL (LUY) ybJ-1001 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS '1 tr 26: C•� a(`l� CITY/ZIP ,]fiaC}��yj f� C ✓7, r CROSS STREET O,�r6r17 Sf-S/�ti APN j-7 1J7JJ I PARCEL SIZES, 3� OWNER NAME V4 -L( C.k G 'Z a e rn PHONE OWNER ADDRESS/�/�-7GAt,, �Q CITY/STATEIZIP CONTRACTOR 1I 11�-t_rs /�'/ 4Zi��d"C/ � i PHONE CONTRACTOR ADDRESS jun (3.0V (f I C) CITY/STATE/ZIP e4 LICENSE ❑l -,C-42 EI.IC-36 OTHER M: — NUMBER&e7&5:5-_HEXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # i LAND USE APPLICATION # 7 TYPE OF WORK: I . NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT �C1--Id I OUT -0F -SERVICE SEPTIC SYSTEM I: DESTRUCTION INSTALLATION WILL SERVE: Zj,4t€SIDENCE ❑ COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: ' NUMBER OF BEDROOMS: .J NUMBER OF EMPLOYEES: ❑ ❑ ❑ SEPTIC TANK GREASE TRAP LIFT STATION TYPE/MFG CAPACITY gal # OF COMPARTMENTS TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) R/CEACH LINES LEACHING CHAMBERS ate # OF LINES 3 LENGTH OF LINES 5S ft Invoice # Permit ID# DISTANCE TO NEAREST WELL 1801 ft FOUNDATION 175) ft PROPERTY LINE I t7r ft ❑ FILTER BED WIDTH ft LENGTH T 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 / W' PITS NUMBER WIDTH (i If ft DEPTH d5 ft DISTANCE TO NEAREST WELL�I -r,A1 ft FOUNDATION le) I ft PROPERTY LINE S / ft 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. IvIlIYIlIfluiVI 'i 1'7 U HV VH/YIrC 1VU I1LIC r[C VIr[CU rVPC Ilyor-a iIIVI11J - rLCHJC IiHLL LV: SIGNED TITLE nyj I(/I G <-dk VY_ DATE DEPARTMENT USE ONLY "t° -!AL Application Application Accepted By—/—y Date /3 Area 1 Employee ID# Final Inspection By 4�E;