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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 />IVUN-MtFUNUAbLt Yt MI I (.ALL LUJ VDJ-/OJ/ t -UK INSYLCIIUNS t-XPIRE5 I TZAR FROM UATE 155UEt <br />JOB ADDRESS r -�6 /',( CrrY/ZIP 4f <br />/ / O Ll <br />CROSS STREET /tea Q 51/ 1 APN `Z/ S _J 4/ - /T PARCEL SIZE �_ <br />OWNER NAME ~�/ 14A11"'.4 /J i AX /�� <br />W /�'PHONE <br />OWNER ADDRESS 1/ a — /&' " CITY/STATE/ZIP & ✓�J ^�y <br />CONTRACTOR Qe,4 PHONE 6f=�' pb— "2 '6� S <br />CONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE ❑.1C-42 0=C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />I BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION _ REPAIRIADDITION _ ENGINEER DESIGNED /ALTERNATIVE <br />_ REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM _ DESTRUCTION <br />INSTALL ATIONWILL <br />SERVE: RESIDENCE ❑ COMMERCIAL ^{� El OTHER <br />NUMBER OF LIVING <br />UNITS: NUMBER OF BEDROOMS: \J NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPEIMFG 4 L \ ► CAPACITY gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />CY LEACH LINES <br />[7 LEACHING CHAMBERS # OF LINES ( LENGTH OF LINES <br />ft <br />1 \ <br />DISTANCE TO NEAREST WELL. M 4f: ft FOUNDATION -f ft PROPERTY LINE f <br />ft <br />❑ FILTERBED <br />WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />It <br />❑ MOUNDED <br />WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH It LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO Mc'noWELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />SEEPAGE PITS <br />NUMBERy_ "1 WIDTH 211 ft DEPTH �� <br />ft <br />DISTANCE TO NEAREST WELL I ft FOUNDATION &) ft PROPERTY LINE I + <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 SC Received eck Amount Date Permit/ Invoice# Permit ID# <br />Code INFO as Remitted Service Request # <br />fii,iI 521 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />