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ONSITE WAS'T'EWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENV moNMENTAL HEALTH DEPARTMENT 104 E WEBER AYE-3""FL-SrOCKrOS CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE <br /> PERMIT p`C,/A�LL(209 953-7697 FOR INSP£CTIOUS ,t EXPIRES I VEARFROM <br /> 1DATE <br /> 'ISSUED <br /> JOB ADDRESS L 0 � W_-k V, _.. CITizip <br /> CROSS STREET <br /> S APN � 0 PARCELSIZE .4�.�►1 e <br /> ' r\ . R <br /> OW'JF.R NAME. PHONE <br /> ON'NERADDRESS _ _ CITVISTATF./ZIP_ y 2 <br /> CONTRACTOR __ PHONE _1>6 T '7 <br /> i� <br /> I! CONTRACTOR ADDRESS O CtlrYISTA'FE/ZIP g <br /> I <br /> LICENSE ❑CA2 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER I ABLE DEPTH: fr GF.OGRAPIUCALINFORMATION: Coordinates X Y C <br /> PER("PEST # 'I <br /> L, I BUILDING PERMIF# _. LAND USE APPLICATION# lA- -dIGnOf"Z 4) , <br /> TYPE OF WORK: J NEW INSTALLATION ❑ REPAIR/ADDI"FION J ENGINEERDESIGNF.DIAI.TERNATIVF <br /> ❑ REPLACEMENT ❑ DES'TKUCI'ION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER .� <br /> NUMBER OF LIVINC UNITS: NLMHER OF BEDROOMS: NUMBER OF EMPLOYEES: 'v <br /> ❑ SEPTICTANK IYPE/MFG CAPACITY gal #OF COMPARTMENTS — <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #Of COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WFTT ft FOUNDATION R PROPERTY LINE fl <br /> ❑ LIFT STATION SIzE TYPE OF PUMP ❑ SAND 011.SEPARATOR(ENCI.oSED SYSTFm) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF I.TNrs LENGTH OF LINES <br /> DISTANCE TO NEAREST W'F.LI. ft FOUNDATION _ II PROPERTY LINE - _ _ _ A <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH.------__-.—. -_ _ ____R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED Win IH ft LENGTHit DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPER'I Y LINE ft <br /> U SUMPS WHTI'H ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION tt PROPER IY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ti DEPTH it <br /> DISTANCE TO NEAREST WFIA ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMHFR WIDTH tt DEPTH ft <br /> DISTANCETONEAREST WELL R FOUNDATION R PROPER'T'Y LINE 1t <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL RR DON F.IN ACCORDANCE.WITII SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 OUR ADVANCE NOTICE.REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 !/ N <br /> SIGNED 1'1'ILk:(.,�o�.,,.S�-�'4'"r UAT'E `6 2, /) Q5t� <br /> I <br /> D p - <br /> DEPARTMENT VSE O LY - <br /> Application Accepted Rv _ Date 0 C Arca Employee ID# <br /> Final Inspection By i _ _ Date ❑ SPECIAL PERMIT-Approved by <br /> Character of <br /> 'oil to Dcpl T 3 Ft: P USump Soil Character: <br /> COMMENTS <br /> PE SC Received CheckitI Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ByGG ash ,Remitted Service Request# <br /> 222 5-24 \v D �Icll O S t� 20 J�Jr J� <br /> 42-02-001 ONSITF W'ASTFWA'I ER?FRMI'I <br /> 12222003 <br />