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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 (209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR Septic Services Group PHONE 916-203-6259 <br />CONTRACTOR ADDRESS PO Box 569 <br />CtrdSTATE/Zip Wilton, CA, 95693 <br />7 k) Tar Z t1/4.X2-1e- <br />eA. V <br />&-x...) <br />if 7( lx) TZ,viZ <br />Crry/Zip <br />APN OJ c 0'; ) PARCEL SIZE L l , CDF <br />PHONE 'fis----71t - <br />12-011 CITY/STATE/ZIP <br />LICENSE ' C-42 0 C-36 OTHER "A' <br />WATER TABLE DEPTH: 0)3 <br />PERC TEST <br />TYPE OF WORK: NEW INSTALLATION <br />REPLACEMENT <br />NUMBER 1068208 <br />BUILDING PERMIT # <br />EXPIRATION DATE 8'31'2022 <br />LAND USE APPLICATION # <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> <br />INSTALLATION WILL SERVE: <br />RESIDENCE <br /> <br />COMMERCIAL _ OTHER <br /> <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />TYPEJMFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />LIFT STATION SIZE TYPE OF PUMP 0 PKG TX PLANT 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />tg LEACH LINES LEACHING CHAMBERS # OF LINES i LENGTH OF LINES 4 Z-' ft <br />DISTANCE TO NEAREST WELL 1 0 0 + ft FOUNDATION / 0 ft PROPERTY LINE 10 ft <br />CI FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SUMPS WIDTH Z -. ft LENGTH I .2- ft DEPTH i ( ft <br />DISTANCE TO NEAREST WELL / 'so I- ft FOUNDATION J £) 1 ft PROPERTY LINE /ct + ft <br />DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br />R SEEPAGE P NUMBER _ WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE • ft <br />I HERESY 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 7 0!UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2Q91953-7697 <br /> <br /> TITLE RME DATE ;- - "I' - ,7 ' <br /> PAviik <br />—RECENED <br /> MA R 0 4 2021 HetraiJoiRA2Nui:lEcNcrrY <br /> DEPARTmENT <br />PEPARTMENT/Y,E ONLY <br />Area e% Application Accepted B Date .2 <br />Final Inspection By Date-3A3 z Employee ID# <br />oLl SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: PI ump Soil Character: <br />COMMENTS 1-c-, I int; (.> oc_s pyit, J ioi Ai') , JP/15 <br />oi ii,Acki--) pe r CHD <br />PE <br />Code <br />SC <br />INFO_ <br />Received <br />py.... , <br />Checkill <br />Cas <br />Amount <br />Remitted s Date Permit( <br />Service Rensst # Invoice # Permit ID# <br />L-IS4 1.3 IV° (110 (7 4-3°0 30-1 5t2D0 g..35-1-- <br />42-01 <br />4/14/18 dej)(1 /2_153 78-o/ <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />SEPTIC TANK <br />GREASE TRAP <br />SIGNED <br />A a