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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(2091468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR 1NSPECTIOAIS EXPIRES 7 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 23304 S-Hansen Rd. CITrILP Tracy 95304 <br /> CROSS STREET Tsirelas APN 209-360.02 PARCELSIIE 1.64 Acres r <br /> v <br /> OWNER NAME Gesaranee Wongphiboonrat PHONE �+ <br /> OWNER ADDRESS Same CITYIS7A7EZP <br /> CONTRACTOR Live Oak GeoEnvironmental PHONE (209)369-0375 <br /> CONTRACTOR ADDRESS 407 W-Oak St. CnYISTATEIZIP Lodi,CA 95240 <br /> LICENSE ❑--C-42 ❑JC.36 OTHER CEG NUMBER 2151 EXPIRATION DATE 4/3012B <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # 1 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: F. NEW INSTALLATION C REPAIRIADDITION . ENGINEER DESIGNEDIALTERNATNE <br /> REPLACEMENT L OUT-OF.SERIIICE SEPTIC SYSTEM _ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LNRtlG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES_ <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDAION___ ft PROPERTY LINE ft <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIo7H ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft <br /> L] SUMPS WIDTH It LENGTH ft DEPTH ft <br /> DI STANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE 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 fI <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQU IN COUNTY. <br /> MINIM UM 4AMUR A DOWE NOTICE REQUIRED FOR IN P CTIONS-PLEASE CALL 20 9 •75 7 <br /> SIGNED TITLE Project Manager DATE 5`7- _2-6, <br /> Iv e_ <br /> 2026 <br /> P,�co <br /> U <br /> �7 <br /> EPARTMENT 5 <br /> Application Accepted Date Area - T / Employee IDiI —577' <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved Dy <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soit Character: <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permitl <br /> ode INFO B Cash emitted Date Service Re uest# Invoice# Permit ID# <br /> 42-01 ONS ITE WASTEWATER TRT MNT SYSTEM PERMIT <br /> 4M 4!1 B <br />