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'V-I I I I U <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUI14 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 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 28484 Lemon Ave. CITY(ZIP Escalont95320 <br /> CROSS STREET S.Harrold Ave. ApN 249 110 23 PARCEL SIZE 0.81 acres <br /> v <br /> OWNER NAMESOareS PHONE 209-992-0130 <br /> OWNER ADDRESS CITYISTATEMP <br /> CONTRACTOR Terracon PHONE 209-367-3801 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITYISTATEMP Lodi,CA 95240 <br /> LICENSE El-C-42 OCC-36 OTHER C-57 NUMBER 669004 EXPIRATION DATE 5-31-2021 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> K PERC TEST #3 1 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION Lt REPAIR/ADDITTDN rl ENGINEER DESIGNED/ALTERNATIVE <br /> r- REPLACEMENT D OUT-OF-SERVICE SEPTIC SYSTEM :1 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPEIMFG _ CAPACITY gal NOF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES _I LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE it <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 6iVLMUMII H0URAQVANQE NOTICE REQUIRED FOR INSREC NS-PLEASE CALL(2091953-769 <br /> SIGNED, TITLE DATE jjjj:�)j <br /> • <br /> i <br /> w <br /> N 1R <br /> H E R M N <br /> Application Accepted By�� Date / Cl Area --1Employee IDN <br /> Final Inspection By Date ❑ SPEC11w PERMIT-Approved by <br /> Character of SOI[to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Code INFO B Cash Remitted Dale Service Re ueel M Invoice# Permit IDM <br /> t-zz S�� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4!14!15 <br />