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r <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER N <br />0 <br />PHONE <br />OWNER ADDRESS <br />GALL <br />ZUY 953-7697 FOR INSPECTIONS <br />11 YEAR FROM DATE ISSUEI <br />ElX <br />Lac-i^ <br />( <br />CITY/ZIP S <br />,PIRES <br />C(< 1fjo `01 <br />I <br />/ <br />P'IAG, <br />APN V D 1 <br />C� PARCEL SIZE `� <br />L / <br />LICENSE 11 <br />LICENSE OTHER (2AIt <br />�'a >4 <br />n <br />' NUMBER %0337 EXPIRATION DATE <br />0 <br />PHONE <br />OWNER ADDRESS <br />SC Received C Amount <br />Date <br />CITY/STATE/ZIP <br />❑ PERC TEST # <br />jJ <br />CONTRACTOR l'rySr`0,I-P <br />� C'a <br />ddy0,,li1,S' <br />(( r nn <br />� D(L✓�61rNg PHONE <br />pp <br />CONTRACTOR ADDRESS i %J �\� IT <br />P'IAG, <br />Q✓e, CITY/STATE/ZIP M6(n4- <br />C ;; CC 4' <br />L / <br />LICENSE 11 <br />LICENSE OTHER (2AIt <br />�'a >4 <br />n <br />' NUMBER %0337 EXPIRATION DATE <br />J7 - 3 <br />COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING <br />WATER TABLE DEPTH: <br />SC Received C Amount <br />Date <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />Code <br />BUILDING PERMIT #j5f <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION <br />❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMEN <br />❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL <br />SERVE: RESIDENCE <br />❑ <br />COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING <br />UNITS: <br />NUMBER OF BEDROOMS: 13 NUMBER OF EMPLOYEES: <br />>SEPTIC TANK <br />TYPE/MFG <br />b <br />CAPACITYgal # OF COMPARTMENTS Z <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />LlPKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />X—LEACH LINES <br />ElLEACHING CHAMBERS <br />#OF LINES �LENGTH OF LINES ft <br />/D <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION_ ZO ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TOEST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />EEPAGE PITS <br />NUMBER <br />-;SWIDGIift DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />FOUNDATION ft PROPERTY LINE 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 <br />SC Received C Amount <br />Date <br />Permit/ <br />Invoice # Permit ID# <br />Code <br />INFO B Cas Remitted <br />ervice Re uest # <br />42-01 ONSITE WASTEWATER TRTMINT SYSTEM PERMIT <br />4/14/18 <br />