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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-KEFUNDABLE NERMII <br />UALL (ZU,9) 95J -/6y/ FOR INSPECTIONS - LXPIRES I YEAR FROM UATE ISSUE <br />JOBADDRESS V� <br />/y���_ G#" <br />C�� ✓� • CITY/ZIP�� <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />-/ �� <br />gal # OF COMPARTMENTS <br />CROSS STREET <br />DISTANCE TO NEAREST: WELL <br />APN U <br />PARCEL SIZE <br />r ,, �D <br />OWNER NAME � `'Y1 (G <br />�� <br />PHONE <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />OWNER ADDRESS / �+ <br />\n C �� cti �- CITY/STATE/ZIP <br /># OF LINES <br />CONTRACTOR )e <br />� �- Cr <br />PHONE <br />ft FOUNDATION <br />,-CJ/- <br />CONTRACTOR ADDRESS / yJ `� <br />c <br />/ Q�%V �i �� <br />f��'�� <br />C/ /CITY/STATE/ZIP /Odle//•f. <br />/ J�-rJ <br />LICENSE ❑LIC -42 ❑LIC -36 OTHER <br />NUMBER_�)f 5 7�� EXPIRATION DATE PC3 <br />1 Z 3 <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION 6 REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />F. REPLACEMENT ❑ OUT -0F -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />Permit ID# <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 />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />15 FILTER BED <br />WIDTH /Q ft LENGTH <br />�421_ ft <br />DEPTH l ft <br />DISTANCE TO NEAREST WELL Ly r ft FOUNDATION 3 �- <br />ft PROPERTY LINE f G ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />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 />MINIMUM 0 <br />HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />/ <br />SIGNED <br />TITLE �+1r. f V ^ <br />DATE <br />Application Accepted By <br />Final Inspection By ! �-_ <br />Character of Soil toDepthDepth o <br />COMMENTS jllktitl - <br />DEPARTMENT USE NLY(�C� _w <br />Date I 29 'Z( Area / / Employee ID# .`�°� ` <br />Date 1 t v ❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />lkerk2S 5iz1:, xI-4'L A,aU,o,cr 1Mos� A 44" -1k, <br />V <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />z- a <br />/�,� <br />V a <br />D 5 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />