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ONSITE WASTER TREATMENT SYSTI. -,IRMIT <br /> sl-N JOAQUIN COIJN,ry LN.VIRONMENTAI,HEALTH - 304 E WEBER Ave ---3-1-'1.-S'F'()('K'ION CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMrr CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED. <br /> Lo) <br /> i <br /> CII-OZIP elie7me:A", <br /> JOB ADi)R S', <br /> CROSS STREET APN • PARCEL,IZE V <br /> `4i, PHONE <br /> ONVNER NAME <br /> I.r-f0t�, / <br /> jf CITY/STATEIZIP <br /> 2J Y2 <br /> OWNER ADDRESS <br /> PHONE <br /> CONTRA( "OR <br /> CONTRACTOR ADDRESS ple V CITY/STATFIZIP <br /> LICENSE 0 C42 J C-36 OTHER NuNtBrR EXPIRATION DATE <br /> WATER TABLE DEPTu; 11 GEOGRAPHICAL INFORMATION: Coordinates x y <br /> El -PFRCTEST 4 BUILDING PERMIT#_ LAND USE APPLICATION# <br /> TiTL OF WORK: D NEW INSTALLATION ❑ REPAIWADDITION El ENGINEER DESIGNED/ALTERNATIVE <br /> LI REPLACEMENT J DESTRUCTION <br /> INSTALI,ATfON WILL SERVE: J RESIDENCE J COMMERCIAL LJ 01-HER <br /> NUMBt;K OF LIVlNC UNITS: NUMBt,K OF BEDROOMS: NUh1RF.R OF EMPLOYEES: <br /> ❑ SLPTICTANK CAPACHY gal 40FICOMPARTMENTS_ <br /> LI GREASE TRAP TYPE/MIto CAPACITY gal P OF COMPARTMENTS <br /> LI PKG TX PLANT DI.STANCEToNVAREST: WELL ft FOUNDATION fl PROPERTY LINE n <br /> 0 LIFT STATION SIZE TYPE OF PUMP 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES El LEACHING CHAMBERS #OF LINES- LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL f1 FOUNOATION_. ft" PROPERTY LINE ft <br /> C3 FILTER RED WIDTHft LENGTH itDEPTH ft <br /> DISTANC..F.To NEAREST WELL- ft FOUNDATION It PROPERTY LINE ft <br /> C3 MOUNDED WIDTH ft LENGTH f DEPTH <br /> ft <br /> DISTANCE To NEAREST WELL N fi PROPERTY LINE ft <br /> El sumps WIDTH It LENGTH DEPTH ft <br /> DISTANCE To NEAREST WELL_ N ft PROPERTY LINE ft <br /> 0 DISPOSAL PONDS WIDTH- ft LENGTH ft DEPTH 11 <br /> DISTANCE To NEAREST WELL_ 11 FOUNDATION ft PROPERTY LINE ft <br /> LI SEEPAGE Prrs NuNiOl".11 Win I'll ft Di:Piii ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ti PROPERTY LINE IS <br /> I HEREBY C TIFY THAT 9AVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> RDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> HOUF ADVANCE NOTICE REQUIRED 1,011 INSPECTIONS-PLEA.St:CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> FF <br /> )d <br /> F <br /> 117 <br /> N <br /> I L <br /> DEPARTMENT USE ONLY <br /> Application Accepted B Date Area Employee]D# <br /> Final Inspection Date El SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth hf J Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> Chec Amount Permit/ <br /> PE SC ReceivedDate Service Request 4 Invoice# Permit IDP <br /> Code INFO By Cash Remitled <br /> ',2,;Z 0? <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12122/2003 <br />