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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAzELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 13550 Highway 12 ,.CITY/TIP Lodi,CA 95242 CROSS STREET Potato Rd. APN 055"020-02go* PARCEL Sig 12.0 Ivo OWNER NAME Joe,Grindstone Association PHONE {n_ OWNER ADDRESS 1029 N.Country Club CITY/STATEaW Stockton,CA 95204 7n CONTRACTOR T2Conetrmton PHONE(209)617-0945 CONTRACTOR ADDRESS 2175 Dunn Rd ,�+7 CLTY/STATE/ZIP Merced,CA 95340 1 LICENSE ,; C-42 ❑' C-36 OTHER �f/1(^G NUMBER PLr / EIIPIRAnoN DATE�� WATER TABLE DEPTH: 12 R GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION TYPE OF WORK: i I NEW INSTALLATION I I REPAWADDITION I 1 ENGINEER DESIGNED/AL RNA kX REPLACEMENT WW Holding Tank I I OUT-OFSERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL B OTHER Private Campground NUMBER OF LIVING UNITS: U NUMBER OF BEDROOMS:0 NUMBER OF EMPLOYEES:t ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST. WELL it FOUNDATION It PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES 11 LEACHING CHAMBERS #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it ❑ MOUNDED WIDTH it LENGTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH it DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl (3 SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. REQUIREDFOR PLEASE CALL(200)953-M7 O SIG TITLE DATE RF YMF)v r CF j��o N��C 3,9?020 S E E A TITA C H E D P L A N S A N D S U B M I T T A L S V 4QU/N TNR0NMECOUNT pFpq R��NTY RTMEN LY Application Accepted By Date Area Employee Final Inspection By Data t I ❑ SPECI PERMIT-Approved by Character of Soil to Depth of 3 Ft: PitlSump Soil Cha cter: COMMENTS P . e � T it{.(s - PE SC Received Checkffl CheckAmount Date Permit/ Invoice# Permit ID# Code INFO B ash Rem Service Request# 52. 4114/ &%14 `/ `//� ^,/ ONSRE WASTEWATER TRTMNT SYSTFJ�A PERMR4!14118 ! ` ` (`0�7/ `��/•fi(J