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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEA' 'EPARTMENT 304 E WEBER AVE-31"FI )CKTON CA 95202-(209)468-3420 <br /> was, NON-REFUNDABLE PERMIT �ftlpo," CALL 209 953-7697 FOR INSPECTIONS EX 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1!2r,"� + i V S 1 ri L f t�yr N G./:• �.c-c CITY/zIp f-Z 1 ic.-t 7 ••'�t[,r`' <br /> CROSS STREET 1�L: APN I4���?"Ci- I - l 7� <br /> PARCEL SIZE `T'"� Z 1 o <br /> — OWNER NAME 1 - S\01'••F 3 IF-, I-J G Y YN 4n'• AV-4L- PHONE L4 t✓-1 L�Z <br /> fir- r •` � t r^ <br /> OWNERADDRESS t E -r c� - r - �fi t C �f , ' CITY/SI'ATE/ZIP <br /> CONTRACTOR i.t.`I ( r-� [I C., t t l, (�L'f PHONE <br /> r• CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> r IN PERC TEST # Z BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ PREPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> Now NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gel #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> tttr <br /> ❑ LIFT STATION SIZE TYPE OF Pump ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> saw DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DLSTANCETO NEAREST WELL It FOUNDATION ft PROPERTY LME ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> r <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT I 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 /> IINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> i <br /> i/At TITLE <br /> SIGNED DATE [ / / <br /> *� 1`.rel <br /> I <br /> FE <br /> c <br /> i <br /> H H PE'AF TM NT <br /> 7 <br /> DEPARTMENTIIS ONLY' <br /> °+ 2 Area / Employee ID# <br /> Application Accepted By !C'�I.�L'J'7�'� , ate F � �%r <br /> Final Inspection By 7 Date ❑ SPECIAL PERMIT-Approved by / <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS M •n i t <br /> a. - <br /> PE SC Received heck# �Amoun Permit/ <br /> �--J�. Invoice# Permit IDN <br /> Code INFO B Cash Service R uest# <br /> .5 i'u 5,£! r <br /> 42.02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />