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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 21952 S.Van Allen Rd CITY/LP Escalon 95320 v, <br /> -I <br /> CROSS STREET River Rd APN 24524010 PARCEL SIZE 63.51 acres a <br /> 0 <br /> OWNER NAME Ann Loogman PHONE 4847678 m <br /> OWNER ADDRESS 22202 S Van Allen Rd CITY/STATE/ZIP Escalon,Ca 95320 <br /> CONTRACTOR Modesto Sand and Gravel,Inc PHONE 545-4425 <br /> CONTRACTOR ADDRESS 6137 Hammett Ct CITY/STATE/ZJP Modesto,Ca 95358 <br /> LICENSE tl C-42 t 1.C36 OTHER C-21 NUMBER 271166 EXPIRATION DATE 02/28/2021 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAWADDITION _ E <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION o1SePIcTank <br /> INSTALLATION WILL SERVE: I I 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 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 i LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft 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 WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 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 HOUR ADYANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED —�� ��" TITLE Project Manager DATE- <br /> i <br /> 71 <br /> Iv 11 11 r11 - �I VFD <br /> 102020 <br /> UIIV Cp <br /> ij <br /> PART TAC <br /> MENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted y Date O Area I 1 Employee ID# � <br /> Final Inspection By Date Z LJ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Pit/Sump Soil Character: <br /> COMMENT - D <br /> rano I,e C421;Ad <br /> PE SC Received eck Amount Date Penult/ Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Re uest# <br /> e 57015-1 �o sp 1D�5 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />