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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P,/ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL70/9'9953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM UATE ISSUE[ <br />JOB ADDRESS u CITY21P 540 CO -on L <br />CROSS SnocTREET APN +• ` PARCEL SIZE . <br />I �NER NA E � _ ___ PHONE <br />' / I <br />OWNER ADDRESS L/ CITY/STATE/ZIP 'll f� <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ iC-42 ❑ C-36 OTHER <br />NUMBER _ EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />__- ,_ Y <br />I PERC TEST # <br />Amount <br />Remitted <br />Date <br />BUILDING PERMIT # <br />_ _ LAND USE APPLICATION # <br />Permit ID# <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESI E TERNA E <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: ElRESIDENCE <br />ElCOMMERCIAL <br />F1OTHER <br />LNUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />LK SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■ice■ ■■■I■■■■I �h�7■■■■C�;�C!■■■■■■■■■■■■ii■■■■ <br />■■■■■■■■■■iii■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■�!■!■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />Final Ins ection By <br />• i L.c �F • A 5171 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01\jv �" `` �b ` " V ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />