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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 IVUN-MtrurvUAt$Lt rtKMI I GALL LUy y53-fbVf FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS F Q CITY/ZIP S4 6GK IL, d\ (fA CROSS STREET Vn R^C f �O S 1Q APN f `�(T (� (C� j "01: I r T ARCEL,SIZE rr OWNER NAME rfr. ti L yy (��'S C PHONE OWNER ADDRESS C, 'sq!5-L �CCf��yYb(� /-/) CITY/STATE/ZIP4-pGtc CONTRACTOR_M ( I S GGI<PHONE M nLS— CONTRACTOR ADDRESS P/S V80y S n CITY/STATE/ZIP ✓/ tG✓N�-�Gg /G/%` ! J J3 (j LICENSE ❑❑C-42 ❑❑C-36 OTHER ( NUMBER �r�OXPIRATIONDATE (��rr WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: CO rdina S X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM n DESTRHCTinN INSTALLATION WILL SERVE:ESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑"'SEPTIC TANK TYPE/MFG / CAPACITY ! as gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS WIDTH DISTANCE TO NEAREST: WELL 9-6'r ft FOUNDATION In, ft PROPERTY LINE 3s I ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS # OF LINES _� LENGTH OF LINES ft DISTANCE TO NEAREST p WELL (/ll►^.�t7� ft " FOUNDATION ( 6 f ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft ervice Request # 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 --'SEEPAGE DISTANCE TO NEAREST WELL ft r, FOUNDATION ft PROPERTY LINE ft ` 0 PITS NUMBER 3 WIDTH ft DEPTH 9S ft DISTANCE TO NEAREST WELL I 'apr / ft FOUNDATION (a ( ft PROPERTY LINE .S ft I 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. SIGNED VI\ II\J/"L-,I IVItJ - rLLP1JL- IiMLL ICVJ/ TITLE =-o & r DATE --A a el— unaracter or moll to COMMENTS A PE SC Received Ceck Amount Permit/ Code INFO B ash Remitted Date ervice Request # Invoice # Permit ID# t2-1 .� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 Im