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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 />.VN-Rtr UKUAt3Lt rtKMI I /.ALL LUy VOJ- I OV I VUK I1VJYtC1IUIVS CAHIKLb7 T LAK t-KUM LOA I L ISSUt <br />JOB ADDRESS O� 00(-'YJO( CITY/ZIP Manteca 95336 <br />��11 l <br />CROSS STREET Moffett Blvd APN U LI l7'S� PARCEL SIZE 13.63 <br />OWNER NAME Tesoro Commons PHONE 209-490-2313 <br />OWNER ADDRESS 1463 Moffett Blvd #5 CITYISTATEIZIP Mwt—, Ca 95336 <br />CONTRACTOR Modesto Sand and Gravel, Inc. PHONE 209-5454425 <br />CONTRACTOR ADDRESS 6137 Hammett Ct CITY/STATE/ZIP Modesto, Ca 95358 <br />LICENSE ❑ IC -42 GI IC -36 OTHER C-12 C-21 NUMBER 271166 EXPIRATION DATE 2123 <br />D <br />WATER TABLE DEPTH: <br />it GEOGRAPHICAL INFORMATION: Coordinates X Y <br />_ PERC TEST # <br />BUILDING PERMIT # <br />Date Parm lU invoice # Permit ID# <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION - <br />REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />It <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC <br />SYSTEM >,5' DESTRUCTIO N Septic Tank <br />INSTALLATION WILL <br />SERVE: I-'. RESIDENCE <br />r 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 />❑ MOUNDED <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE R <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG T% PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br />Check#/ <br /># OF LINES <br />Date Parm lU invoice # Permit ID# <br />LENGTH OF LINES ft <br />INFO l <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />0S- <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />it <br />FOUNDATION <br />ft PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE It <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />It PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />ft PROPERTY LINE ft <br />1 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 />I M 48 H01JR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CL 209 9534769, <br />SIGNED TITLE Project Manager DATEol <br />lr C <br />DEPARTMENT USE ONLY <br />_r. r'l -' I' r I .I ... r <br />DEPARTMENT U SE ONLY <br />Application Accepted By Data L d Area S G11 �tc Employee ID# v <br />Final Inspection By Date"�/ 11 j - I ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth QTr3 Ft: ./ Pit/Sump Soil Character: <br />COMMENTS_,J- oh1 tr,ns fo be �r` r� LOte>]nr lI^fro �" �.1 tlr^C Of QPTMITI+)C <br />sfrve-hifes Le drm fizehed <br />PE <br />SC Received <br />Check#/ <br />Amount <br />Date Parm lU invoice # Permit ID# <br />Code <br />INFO l <br />Cash <br />Remitted <br />Service Request # <br />yea 1 <br />0S- <br />3 1'Z <br />Isa <br />T�1'Zi; 1083(O1 <br />42-01 <br />4114118 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />