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t � t <br />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 CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CI <br />AA ,, [y r jr TY/ZIP C -E o G <br />AJ L <br />CROSS STREET ( G1sei �C� AP D 1 � O d v 0 � PARCEL SIZE B' �^ <br />OWNER NAME �(a1 +t, C��C�L r P <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR Septic Services Group PHONE 916-203-6259 <br />7- r9Q _ 7460 -`71 <br />CONTRACTOR ADDRESS PO BOX 569 CITY/STATE/ZJP Wilton, CA -95693 <br />LICENSE ❑ C-42 -1 C-36 OTHER A NUMBER 1068208 EXPIRATION DATE 8-31-2022 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />IT Ft: Ut WUKK: ^ NEW INSTALLATION <br />KEPAIR/ADDITION LNGINEER UESIGNED /ALTERNATIVE <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />COMMERCIAL�vtt+ .- OTHER <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: S DO �t NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG f n L <br />CAPACITY ­j6MO— gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP 0 PKG TX PLANT I7 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH UNES <br />LEACHING CHAMBERS # OF LINES Z <br />'7 LENGTH OF LINES Q ft <br />�•�� <br />DISTANCE TO NEAREST WE `/ V ft FOUNDATION /0 <br />LL <br />ft PROPERTY LINE S ft <br />❑ FILTER BED <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL It FOUNDATION <br />ft PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />XSUMPS <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />WIDTH 4 ft LENGTH I& ft <br />ft PROPERTY LINE ft <br />DEPTH e ft <br />DISTANCE TO NEAREST WELL 5-6 ft FOUNDATION I D <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH It LENGTH It <br />DEPTH ft <br />DISTANCE TO NEAREST WELL It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL 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 48 <br />UQA &QLVANCETICE REQUIRED FOR INSE&CT40NS - <br />09 953-76-y97 <br />SIGNED <br />TITLE 0 � <br />DATE Z'— C( — Z06 <br />a <br />L <br />/ DEPARTMENT S IV ONLY Q <br />Application Accepted Byv__ Date a7 / Area ` Employee ID#� <br />Final Inspection By [ i_ Date Z SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS tkw SFR- -rIef eYm't not 14 be_ 51522et'' U."i► SPCOi?101 <br />I Code I INFO I - BILL I vCash I Remitted I Date t I Service Request # I Invoice # I Permit ID# <br />42-01 <br />4114/16 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />/33�Z32,� <br />