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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 <br />(:ALL (ZU&) DY/ FOR INSPECTIONS <br />tXPIKES "1 Y tAK I-KUM LJA I t ISJUtI <br />JOB ADDRESS <br />❑ GREASE TRAP <br />tc CITY/ZIP !JC-- <br />vI P L✓'T �n� — <br />n <br />CROSS STREET A <br />�� Gn <br />K L� APN O �� �� <br />PARCEL SIZE S' <br />OWNER NAME <br />S U J� <br />C S`7 I <br />Pit en 1 3 S5; 'I <br />PHONE <br />OWNER ADDRESS <br />tT a <br />V� 1ti e f i ewe; VI Ly, '-,ft CITY/STATE/ZIIP� <br />(/ <br />S C 1 L) <br />CONTRACTOR <br />Y� �(' <br />(/Ps / / �`�'�Gl <br />S �'��� G Yc tl PHONE <br />CONTRACTOR ADDRESS 10(7) <br />_ Y L! S (� CITY/STATE/ZIP <br />Y' ���L Gi4 ` �►�i ! S J,�(J <br />LICENSE [10C -421111C <br />-36A <br />-EXPIRAON DATE <br />-C-36 OTHER f NUMBERTI <br />^L <br />1$ (�] O i <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # a 10 t? 4 (? a LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: LAY KESIDENCE ❑ COMMERCIAL 11 OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -1 NUMBER OF EMPLOYEES: <br />01 -SEPTIC TANK <br />TYPE/MFG etL. <br />CAPACITY )-S00 gal <br />#OF COMPARTMENTSsL <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal <br /># OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL I a b' ft <br />FOUNDATION J G I ft <br />PROPERTY LINE -) <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ <br />PKG TX PLANT ❑ SAND OIL <br />SEPARATOR (ENCLOSED SYSTEM) <br />01 LEACH LINES ❑ LEACHING CHAMBERS <br />❑ FILTER BED <br />❑ MOUNDED <br />❑ SUMPS <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL__( el al ft <br />ft LENGTH <br /># OF LINES 9_ LENGTH OF LINES <br />FOUNDATION 7 C4' ft <br />ft DEPT[ <br />WELL ft FOUNDATION <br />ft LENGTH <br />WELL ft FOUNDATION <br />ft LENGTH <br />WELL ft FOUNDATION <br />PROPERTY LINE <br />ft PROPERTY LINE <br />ft DEPTH <br />ft PROPERTY LINE <br />ft DEPTF <br />ft <br />PROPERTY LINE <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />Q' SEEPAGE PITS NUMBER 1 WIDTH `' 4 / ft DEPTHS ft <br />DISTANCE TO NEAREST WELL 13A ft FOUNDATION ft PROPERTY LINE -7Q ( 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 />SIGNED <br />Wr[ /IY0!-CIi1IVIVJ - r-L-CPiJG l+P7LL (LVJI J.IJ-/VJ/ ^f <br />TITLE C -o r%jLf'-G4-t+,(- DATE,? <br />Application Accepte2epp <br />� Date cr Areah `� `1 Employee ID# <br />Final Inspection By Date El SPECIAL PERMIT -Approved by <br />Character of Soil to of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS /JeVJ 5f -(Z. fJro-reloctd Tte-r <br />PE SC <br />Code INFO <br />Received Ch / <br />B <br />Amount Permit/ <br />at Service Re uest # <br />Remitted <br />Invoice # Permit ID# <br />Hal�� 0_7 <br />I C�Cash <br />I \� <br />t �ry <br />TS?I l 0 , <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />