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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3""FL-STOCK'1ON CA 95262 -(209)468-3420 <br /> NON-REFuNDABLI{EPERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FRO/M�DATE ISSUED <br /> JOB ADDRESS _I I 0 CITv/zIP 1-01>4 -1 'Z <br /> :DAN\ APN Q O -� 2r PARCEL SIZE <br /> I CROSS STREET k S �2 l� -,/�/.�O o <br /> O <br /> OWNER NAME PIIONF. Y <br /> OWNERADDRESS _. CITY/STATE/ZIP 2 2 <br /> f <br /> CONTRACTOR PHONE ' 76� 7 <br /> I <br /> �. CONTRACTOR ADDRESS_ _ O CITY/STA'Iti/ZIP ;Zj I <br /> 1 <br /> LICENSE :3C42 ❑C-36 OTHER NUMBER EXPIRATIO.N DATE <br /> WATER TABLE.DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERM[T# LAND USE APPLICATION# M—6700o41-2-1 <br /> TYPE.OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED IALTCRNATIVF. <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER .� <br /> NUMBER OF LI VINO UNITS: NLMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 'v <br /> ❑ SEPTICTANK TYPE/MFG _ CAPACITY gel #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WF.I.1. ft FOUNDATION ft PROPERrY LINE R <br /> ❑ LIFT STATION SIZE TYPEOF PUMP ❑ SAND OIL SEPARATOR(ENCLo5rDSYSTEm) <br /> -- O <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _._ LENGTH OF LINESfl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH -_ _ --fl DEPTH <br /> DISTANCE TO NEAREST WELL _ _R FOUNDATION R PROPERTY LINE B <br /> ❑ MOUNDED WIDTH 1t LENGTH_ _ft DEPTH fl <br /> DISTANCE.TO NEAREST WELL _ _ _ ft FOUNDATION � It PROPERTY LINE fl <br /> • SUMPS WIDTH it LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL_ it FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTII ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINF. ft <br /> ❑ SEEPAGE PITS Numitvk WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION B PROPERTY LINE ft <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 /> MINIMUM 24OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �/ N <br /> SIGNED DATE <br /> S UA'1'E <br /> i <br /> lag: <br /> Vcc U <br /> qw <br /> D A <br /> DEPARTMENT YSE ONLY <br /> .....__ Application Accepted B / Date 12-010k Arca Employee ID# �3 / <br /> Final Inspection By Date.__ � Q SPECIAL PERMIT-Approved by <br /> Character.1,111 to Dept f 3 FI: P USump Soil Chan ter. <br /> COMMENTS / �•� 9mi <br /> PE SC Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INPO BY ash .Remitted Service Request# <br /> Z2Z 5-2- CY Z� /OS.tRJ 2,6 SS <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />