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ONSITE WAS -EWATER TREATMENT SY;�M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH - EPARTMENT 304 E WEBER AVE. -3""FI,-St'OCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT 1 + CALL(209)953-7697 FOR INSPECTIONS q-EyXPPIIR�ES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS I 1" [ �� CITY/LIP !t `S/)rV(O + �_ m <br /> CROSS STREET �' /\'\ D <br /> _..�/���,[t 1 ' �t"'t ,1 APNyV5 I(Q-_QJ - 1 1 _ PnRCEI.Slrr: ��% <br /> OWNER NAME 2-[ 1 1 A � /" ,� n 7`J PIIOIVr: 125 'l _ S114 5 <br /> N <br /> y� ► nom,( <br /> OWNER ADDRESS Z(a �a� /(JY-���� GIvy.J (�2, CITY/STATE/ZIPf �(/�( <br /> CONTRACTOR �f ' l , / PHONE, 26-7-3 -N <br /> CONTRACTOR ADDRESS ZZ �- � (✓� N LN. CITY/STATE/Gill � / (i�" yam} 2--'L <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER , EXPIRATION DATE U (� <br /> WATER TABLE DEPTH: 1t GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST(S) NUMBER i LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIWADDTTION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> t <br /> ALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL Ll OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPF/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE II <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH 1l <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH tl LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WALL Il FOUNDA-1 ION tl PROPERTY LINT: 1l <br /> ❑ SUMPS WIDTH ft LENGTH ft DEP NMMft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION I't co WNW ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH tl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION fl PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED HIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> UM 24 OUR ADVANCE:NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)951-7697 <br /> SIGNED TITLE sr/ r �� K�� DATE <br /> / ROAD - <br /> HIMMAY <br /> :,,,OiF-RMIP <br /> � f <br /> — — -- -- ---- -- - - <br /> a HIGHWAY 99 <br /> DEPARTMENT USE ONLY V /qq <br /> Application Accepted By Gh—\1j Date 1 O) Arca '2 �— Employee ID#_� I( _1 <br /> Final Inspection By 1Gt Date 7 �Q3 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: t/Sump Soil Character: <br /> COMMENTS <br /> PE SC ReceivedCheck#I Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BY Remitted Service Re uc-s # <br /> +111 51) c 7 ``�3 T4 7 <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />