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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-REFUNDABLE PERMIT CALL LUV V7s-/0V/ 1 -UH 1NZ51-tc11v1Va GJIYIKCJ 1 1 CNR 1 RVIYI �r+l �.+�� <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET V Z l V� A P N s -2 -7 y c -i -3 PARCEL SIZE <br />P ` <br />OWNER NAME GQf�/�t�L /DQ`]/��Af� j�PHONE <br />j�1 !� <br />OWNER ADDRESS I��y� 'AL <V"esL! ►`R11DONr CITY/STATE/ZIP <br />CONTRACTOR ,//r,4 PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP �' �f �.Tf <br />LICENSE 11CIC-42 110C-36 OTHER NUMBER/Tye 3 EXPIRATION DATE <br />M <br />WATER TABLE DEPTH: M O ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING f ERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION.)I ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />g REPLACEMENT Mf) GI C ❑ OUT -OF -SERVICE SEPTIC SYSTEM 9 DESTRUCTION toy) <br />INSTALLATION WILL SERVE: 11 RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />'1 <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: Z <br />NUMBER OF EMPLOYEES: <br />/ <br />Ig SEPTIC TANK TYPE/MFG C/� <br />G�P' <br />CAPACITY �z U <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />ft DEPDISTANCE TH <br />CAPACITY <br />gal # OF COMPARTMENTS_ <br />DISTANCE TO NEAREST: <br />WELL <br />ft FOUNDATION S , <br />ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />El PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />■ LEACH LINES 0 LEACHING CHAMBERS <br /># OF OF <br />DISTANCE To NEAREST WELL <br />ft FOUNDATIONPROPERTY <br />1111111 FILTER BED WIDTH ZO ft LENGTH <br />elll�x -ft DEPTH / q a)'whes ft <br />DISTANCE To NEAREST WELL /,p -.2 ft FOUNDATION /10 ft P <br />■ MOUNDED WIDTH ft LENGTH <br />ft DEPDISTANCE TH <br />NEAREST WELL <br />ft FOUNDATIONPROPERTY <br />* SUMPS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE To NEAREST WELL <br />ft FOUNDAT10NPROPERTY <br />DISPOSALPONDS <br />DISTANCE To NEAREST WELL <br />ft FOUNDATIONPROPERTY■ <br />SEEPAGE <br />DISTANCE To NEAREST WELL <br />ft FOUNDATIONPROPERTY <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 />MINIMUM i r 1 'ADVANCE NOTICEREQUIRED <br />FOR INSPECTIONS - PLEASE CALL (209)' <br />SIGNEDTITLE <br />, <br />■■■■■■r■■■■■■■■■e■ee■e■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■[�■lliTiel <br />11�ev�i(��eYrr�f/e■■■��'��'.�M�Z��!!I� <br />■■■■■■■■■■e■ee■eee■eee■■e�eeeee■eeeee■e■■■■■ <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />eck <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re est # <br />Invoice # <br />Permit ID# <br />Nd 14 <br />11,5- <br />43op <br />$1 320 <br />.0 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />