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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 CALL 209 9534697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �1 L CITY/Zlp ' 1. <br />CROSS STREET IL L) J7N� APN O S C) �G'y�JPARCEL SIZE <br />OWNER NAME�I� I V(L /f,L �U �,(% _��j <br />PHONE "`���✓����`� <br />OWNER ADDRESS r � in [� Nl.it L (p 2 �%l CITY/STATE/ZIP _( /ray I <br />CONTRACTOR Septic Services Group PHONE 916-203.6259 <br />CONTRACTOR ADDRESS PO BOX 569 CITY/STATEIZIP Wilton, CA, 95693 <br />LICENSE ❑._C-42 ❑uC46 OTHER A" NUMBER 1068208 EXPIRATION DATE 8-31-2022 <br />WATER TABLE DEPTH: S a ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # —� <br />TYPE OF WORK: ... NEW INSTALLATION _ REPAIR/ADDITION i.1 ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT•OFSERVICE SEPTIC SYSTEM IlEami icnnu <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TY <br />PE/MFG CAPACITY gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS_ <br />DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />1" LEACH LINES LEACHING CHAMBERS #OF LINES q�� LENGTH OF LINES it Z ft <br />DISTANCE TO NEAREST WELL ICL'% "I� ft FOUNDATION 1 _$ PROPERTY LINE�6ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />(3 MOUNDED WIDTH ft LENGTH ft DEPTH it <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINcE-� ft <br />SUMPS WIDTH ft LENGTH Z ft DEPTH 7S ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE /0 ft <br />❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br />li EPTH ft <br />DISTANCE TO NEAREST It <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH <br />SAN <br />JOAQUIN <br />COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />PE <br />Code <br />INFO <br />O <br />Received <br />B <br />SIGNED TITLE RME DATE 3._ c f . �1 1 <br />4/14118 IF ml <br />PE <br />Code <br />INFO <br />O <br />Received <br />B <br />Check#! <br />Castiol <br />Amount <br />Remitted <br />Date <br />PermlU <br />Service Request # <br />Invoice# <br />Permit ID# <br />L) C) <br />S <br />lir vl� �• <br />a9sl Slcrt�0 7S 1i2.9 <br />ASTEWATER TRTMNT SYSTEM I <br />Sri/z <br />VVZaZ( <br />y <br />qQ�/ 021 <br />'J'Ift A4 <br />414r <br />I�cfl� <br />