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SR0083251
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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SR0083251
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Entry Properties
Last modified
6/15/2021 11:00:57 AM
Creation date
6/15/2021 10:53:19 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0083251
PE
4222
FACILITY_NAME
23110 N DUSTIN RD
STREET_NUMBER
23110
Direction
N
STREET_NAME
DUSTIN
STREET_TYPE
RD
City
ACAMPO
Zip
95220
APN
00705013
ENTERED_DATE
2/8/2021 12:00:00 AM
SITE_LOCATION
23110 N DUSTIN RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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SJGOV\tsok
Tags
EHD - Public
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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.9420 <br />IVVN'r1tYUNUAbLt rhKMII (;ALL LUbF FORINSPECTIONS, EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS pt 3) I D E •.)r1t1-A�fP� 2ZI 10 CITY/ZIP64-A-mPy 9S) -7••a <br />CROSSSTREET 1>05 'fes N • a(v Q�y— 13 A. <br />APN w) PARCEL PARCEL SIZE G rTG <br />OWNER NAME SM C I r C/Q C&OAI Lw PHONE 141H-0 0 1 <br />�p / <br />OWNER ADDRESS P•O• VDY. '-+D CITY/STATEIZIP Act A*,%Po C1t 9S12 -o <br />CONTRACTOR 1A V C D 111 GC0 F --N V 10L oN YNI mArrA L- PHONE 3 ED5 - on r <br />CONTRACTOR ADDRESS 4C1 w • o Aie— ST • CITY/STATE/ZIP LAW CA 'tf L'F o <br />LICENSE ❑i IC -42 DOC -36 OTHER C e G NUMBER Z I EXPIRATION DATE Z 2 <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION ❑ <br />REPAIR/ADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />ft DEPTH ft <br />❑ REPLACEMENT ❑ <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />❑ DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT O <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION ft PROPERTYLINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />Date Invoice# Permit <br />Service Re uest# <br />DISTANCE To NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH It <br />DISTANCE To NEAREST <br />WELL <br />it FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft 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 <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />M]N1MUM0bQ1 <br />QyftGE <br />NOTICE REQUIRED FOR INSPECTIONS - PL E CALL (209)953-7697 <br />SIGNED <br />TITLE PAO • ✓11(7.9 • DATE Z - cf- 7,1 <br />1".11-10 1 <br />DEPARTMENT S�EONLY ��Q <br />Application Accepted By `—`e Date ri v7 Area L C �I Employee <br />Final Inspection By FfulntI 3 LID � �k l4d �. Date q j t(j ?O'Lt ❑ SPECIAL PERMIT -Approved by �O�N <br />Character of Soil to Depth of !Ft: Pit/Sump Soil Character: .� <br />COMMENTS Fn., <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />PE <br />SC ReceivedChec <br />Amount <br />Permit/ <br />Code <br />INFO B <br />ash Remitted <br />Date Invoice# Permit <br />Service Re uest# <br />.);z <br />S;9 VF <br />$ cZ <br />.2 SR ZGv <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />
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