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SAN JOAQUIN COUNTY ENOVINSMTELWA' .WATER TREATMENT SYS'YHEALTH EPARTMENT 304 ESM PESRoMIT CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS AVIRES 1 YEAR FROM DATEISSUED <br /> CiTY1ZIP ! <br /> JOB ADDRESS Z CJ �- Q � ✓ o� � <br /> CROSS STREET VAI , ) APN -7=00 = Z PARCEL StzE <br /> v <br /> v <br /> OWNER NAMEPV13�lr-- 0 %-j e PHONE <br /> y <br /> OWNER ADDRESS P_O_ iRo� 21$ b i-c r'_�c �'� 1 CITY/STATE/ZIP 6 y C Nn6" <br /> CTOR " O � PHONE <br /> �t <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP L-n ` 9 t; Z O <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # '2^ BUILDING PERMIT# LAND USE APPLICATION <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAiRIADDITION ❑ ENGINEER DESIGNER/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ 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 /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) �N <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft �1 <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 A FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft =S <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft i <br /> O DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 � <br /> t <br /> SIGNED o TITLE DATE f! <br /> arra <br /> rW � mad <br /> u.aaaa NOTES <br /> [� fix,. <br /> nax <br /> � f qua AaRCFL 2 = <br /> rFSri4Il{I ��^ <br /> ME}iRTEb4s 14LHt7ENS <br /> f a4 <br /> ami " <br /> rro ua a•t <br /> `N n <br /> / DEPARTMENT USE/ONLY USE/ONLYOMN JOAC= ry'7 , I <br /> Application Accepted l D t C Area ee 14d#iv L� <br /> F L N EPART N_ �L <br /> Final Inspection �3 Date ��/�/_ ay ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil o De of 3 F Pit/Sump Soil Character: <br /> r <br /> COMMENTS <br /> PE SCReceived Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 42-02-601 ONSITE WASTEWATER PERMIT <br /> 11n1rrnnt <br />