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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-KEFUNDABLEPERMIT GALL <br />JOB ADDRESS 21200 North Davis Road 2, V � / 1-/ <br />CROSS STREET Peltier Road <br />OWNER NAME Celia Hung <br />OWNER ADDRESS 157 California Reserve, 67667 Hwy 20 <br />CONTRACTOR H1 Drilling <br />CONTRACTOR ADDRESS 1400 Kitchner Road <br />9J.1-/09/ FOR INSPECTIONS �tXPIKt5I TEAK hKOM UAIIt ISSUtl CrTY/ZIP TAeWB62A�— L-i/L7/ L /� /-3 2 2— <br />013-09'+05 & 013-09-36 PARCEL SIZE 17.26 8 9.35 <br />L13 1`11) ..3 U,3- ;".0- m. <br />CITY/STATE/ZIP Bend/ Oregon/ 97701 <br />PHONE 916 213-7231 <br />CrTY/STATE/ZIP Sacramento/CA/95822 <br />LICENSE ❑LC -42 EI -C-36 OTHER C-57 NUMBER 1006095 EXPIRATION DATE 8/31/23 <br />WATER TABLE DEPTH: 39 ft ft GEOGRAPHICAL INFORMATION: Coordinates X 38.177291° latitude y -121.3293540 longitude <br />PERC TEST # z BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: X NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE X COMMERCIAL L 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 />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />Amount Parml <br />Remitted Dat Service Request # Invoice # Permit ID# <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION 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 />HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />TITLE DATE <br />See Plan Attached <br />DEPARTMENTEO ONLY C <br />Application Accepted By — Date Area Employee ID# <br />Final Inspection By ✓I Date SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: PiVSump Soil Character: <br />COMMENTS e'� 3 `"G` j G" .. jS- —01 C'/-3 C50 36 <br />Af4 <br />w <br />0 <br />PE <br />Code <br />SC Received <br />INFO <br />Check#/ <br />Cash <br />Amount Parml <br />Remitted Dat Service Request # Invoice # Permit ID# <br />ZZ"Z <br />42-01 13zo ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />