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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 13901 Carrolton Rd CITY/ZIP Fscalon 95320 v, <br /> P <br /> 1. <br /> CROSS STREET Avena Rd APN 20505022 PARCEL SIZE 10.06 acres c <br /> c <br /> OWNER NAME Robert Holmes PHONE 484-7678 H <br /> OWNER ADDRESS 21444 Blackmore Rd CITY/STATEIZIP Escalon,Ca 95320 <br /> CONTRACTOR Modesto Sand and Gravel,Inc PHONE 545-4425 <br /> CONTRACTOR ADDRESS 6137 Hammett Ct CITY/STATE/LP Modesto,Ca 95358 <br /> LICENSE Ll C-42 L1_.C36 OTHER G21 NUMBER 271166 EXPIRATION DATE 02/282021 <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 11 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION of Septic Tank <br /> INSTALLATION WILL SERVE: LI RESIDENCE L COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 0 LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> 0 FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE It <br /> 0 SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <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 HQUA ADVANC&NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNED TITLE TITLE Project Manager DATEj'�—Z-J <br /> cF� <br /> PARTMEN <br /> US# ON <br /> Application Accepted 8 Date Area "mployee ID# '�A <br /> Final Inspection By Date WOO, L SPE IAL PERMIT-Approved by --� "' <br /> Character of Soil to De th f 3 Ft: PitlSump Soil Character: �q�,d' <br /> COMMENTS 0 vl/2 v FHT <br /> Ll� z — <br /> PE SC Received Che Amount Date Permit] Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Requast# <br /> 419 <br /> o � 3-z.ZL S Z <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14118 <br />