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ONSITE WASTEWATER TREATMLN I 60Yb0 E I r-lyl r S ocICTONCA95202-(209)468-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT' <br /> N <br /> ON-REFUNDABLE PERMIT CALL ,209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED � <br /> Go L-W E t� RSL'• CITYIZIPGFR mftY r o/� APN O 0S _ l4^_0-1PARCELSIZE I`•' • ` ° v <br /> C V A I `� tp43 – �ZrS9 <br /> �'�9'i E-APHONE__ �!F gDpl / �G��'�"}" �\y y° STE• �� I CITY/STATE/ZIP 1�' 'v �s r r '/ <br /> c®&F 4T0 {JG.,v�� Nr('V� '°a� PHONE a� f <br /> CONTRACTOR I►I4i �- L.��I G�9 <br /> �o� OAK }�I CIN/STATE/ZIP '4� <br /> CONTRACTOR ADDRESS N" V <br /> LICENSE QC-42 ❑,C-36 OTHER <br /> NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X�— <br /> Y <br /> BUILDING PERMIT# LAND USE APPLICATION# <br /> FERC TEST # ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> NEW INSTALLATION ❑ REPAIR/ADDITION <br /> TYPE OF WORK: ❑ ❑ DESTRUCTION <br /> ❑ REPLACEMENT <br /> ' ❑ COMMERCIAL ❑ OTHER <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> NUMBER OF LIVING UNITS: <br /> " CAPACITY gal #OF COMPARTMENTS <br /> ® SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> — <br /> • GREASE TRAP TYPE/MFG It FOUNDATION ft PROPERTY LINE ft <br /> DISTANCE TO NEAREST: WELL <br /> L2 LIFT STATION SIZE TYPE OF PUMP_® PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> #OF LINES LENGTH OF LINES ft <br /> ® LEACH LINES ❑ LEACHING CHAMBERS ft PROPERTY LINE ft <br /> DISTANCE TO NEAREST WELL - ft FOUNDATION <br /> ft DEPTH ft <br /> ft LENGTH <br /> • FILTER BED WIDTH___..--- ft FOUNDATION f, PROPERTY LINE ft <br /> DISTANCE TO NEAREST WELL - ft DEPTH . It <br /> ® MOUNDED WIDTH it LENGTH ft <br /> ft PROPERTY LINE <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It DEPTH ft <br /> 0 SUMPS WIDTH ft LENGTH ft <br /> ft FOUNDATION ft PROPERTY LINE <br /> DISTANCE TO NEAREST WELL ft DEPTH ft <br /> ft LENGTH <br /> ® DISPOSAL PONDS WIDTH�-- ft FOUNDATION ft PROPERTY LINE ft <br /> DISTANCE TO NEAREST WELL ft DEPTH ft <br /> ® SEEPAGE PITS NUMBER WIDTH ft <br /> DISTANCE TO NEAREST WELL <br /> R FOUNDATION ft PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS <br /> LAWS AND RN THE WORK WILL BE ULESDAND REGULATIONS OF SAN NOAQUINDCOUNE'rYWSAN JOAQUIN COUNTY ORDINANCES, <br /> COUNTY. <br /> MINIM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 m��_ a� <br /> TITLE C.�S N d.A^ DATE �( <br /> SIGNED <br /> av l <br /> Ills <br /> lQ Ia2 I f <br /> z <br /> II <br /> ' 6 — <br /> s^ \ ---- �LLj o;Z <br /> ,� ;t <br /> bIggii �t^ <br /> ) I 1 <br /> l 10 I <br /> lna , ALM I <br /> 1 <br /> DEPARTME L <br /> Date Area Employee ID# <br /> Application Accepted Bq Date ❑ SPECIAL PERMIT-Approved by <br /> Final Inspection By pitlSump Soil Character: <br /> Character of Soil to Depth of 3 Ft: <br /> COMMENTS <br /> I <br /> —, — Permit/ Invoice# PermitID# <br /> PE SC Received Check#1 Amount Date Service Re uest# <br /> g <br /> Code INFO Cash Remitted <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />