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C���B�"�,m� ��f�4�TEWA►TER TRE��"�IIEiVT SY�TI=TVI PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-Pi420 <br />NON-REFUNDABLE`C�1E�,R\MICT �` (� BALL (2®9� 953-7697 FOR INSPECTIONS EXP(I�RE[S � YEAR FROM ®A.TE OSSUED <br />JOB ADDRESS � 3u� 1Jyv t`�'J �`v1'C:� � I� (� Q � �-� � �dt1 cLlTv/zlP ��(�l l J JU�I <br />CROSS STREET , `�! I �� '✓ Y \ V � APN � 12 — � VD � �� PARCEL SIZE <br />OWNER <br />OWNER ADDRESrS l <br />CONTRACTOR 1 `A1��'►�rI C��{S��'U1�7� (���J� <br />CONTRACTOR ADDRESS `� � ✓ � ' �� � "`- <br />LICENSE ❑LIC -42 ❑I.1C-36 OTHER <br />0 <br />CITY/STATE/I�ZIP/J /� Q <br />`,P PHONE �"tD-(`�-1� -/�Q�� <br />A"` � 2 CITY/STATE/ZIP O��U1 � J <br />PdUMBER J O � � � EXPIRATION DATE <br />( fi <br />WATER TABLE DEPTFI: LD — ___ ft GEOGRAPHICAL INFORMATION: COOrdlnateS X Y <br />❑ PERC TEST # BUILDING PERMIT' # (9flO0?jq LAND USE APPLICATION #_ <br />TYPE OF WORK: � NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESI( <br />D REPLACEMENT [l OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />/ALTERNATIVE <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL `�I OTHER -f V1 (.(S�YI�i- <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG L�C�{P i50� �.)cnSc� CAPACITY ���� gal #OF COMPARTMENTS Z <br />L71 GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />(� LIFT STATION SIZE (� TYPE OF PUMP ZoCII fV ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES ❑ LEACHING CHAMBERS _ # OF Loves LENGTH OF LwEs ft <br />DISTANCE TO NEAREST WELL_ _ ft FOUNDATION ft PROPERTY LINE__ ft <br />FILTER BED WIDTH �d ft LENGTH � '� O ft DEPTH _ � ft <br />DISTANCE TO NEAREST WELL � 5O �% ft FOUNDATION lbw ft PROPERTY LINE 3S'' — ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SUMPS WIDTH ft LEIVGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI ft <br />� DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH D ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft <br />CEJ SEEPAGE PITS NUMBER WIDTH ft DEPTH � ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT /AQUI ft <br />I HEREBY CERTIFY THAT I FIAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUI l�R,�� CES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. NT <br />SIGNED <br />� i, <br />x(111 <br />�� <br />Application Accepted By I�___u <br />Final Inspection By `j'�/ <br />Character of Soil to D�pth� f � <br />COMMENTS (/ rz I! J. <br />DATE �'� S-Z(� <br />2 <br />DEPARTMENT USE NLY / <br />Date Area � � Employee ID# <br />Date ❑ SPECIAL PERMIT -Approved by <br />foil CI <br />.d r <br />�, <br />r <br />A� <br />H <br />lye <br />b� <br />L p+� <br />1 f1; S <br />PE <br />SC <br />Received <br />Check#/ <br />Amount Date <br />Permit/ <br />invoice # <br />Permit ID# <br />Code <br />INFO <br />B <br />Cash <br />Remitted <br />Service a ue t # <br />'..sem-- <br />�bo -� �� Ili <br />x1z� <br />' . <br />42-01 % �J t�.1t� <br />4/14/18 /�����! d ( Z�l / <br />i <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />