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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 21850 East Liberty Rd CITY/LP Clements/95227 n <br /> CROSS STREET CA-88 APN 021-200-24 PARCEL SIZE 4.84 Acres > <br /> v <br /> e <br /> OWNER NAME Yasir Khanshali PHONE(209)6052370 n <br /> OWNER ADDRESS 21850 East Liberty Rd CITY/STATE21P Clements/CA/95227 <br /> CONTRACTOR CTE Cal PHONE(209)543-1799 <br /> CONTRACTOR ADDRESS 4230 Kiernan Ave,Suite 150 CITY/$TATE2IP Modesto/CA/95356 <br /> LICENSE LJ C-42 C C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: Unknown ft GEOGRAPHICAL INFORMATION: Coordinates X 38°14'8.13"N y 121°3'1.10"W <br /> R PERC TEST #a BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT _ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: L RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft 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 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> 1 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNED TITLE Staff Geologist DATE 12/14/2020 <br /> NT <br /> C® <br /> O1D <br /> NTY <br /> D <br /> PAR TMENT USE ONL Y <br /> Application Accepted By Date Z /2') Area Employee ID# <br /> Final Inspection BAData 1 6 1 7 A ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date PertnlU Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service R at# <br /> 47CIA- <br /> 42-01 ` ' ` ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />