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r l'a <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTv ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-91OCKTON CA 95202 -T209)0&'3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS CrTYfZIP w <br /> �7 In <br /> CROSSSTREET t�Je.�-�-sr�AQ.e�.l y^1- ,4 q 4 �i�lx��APN oo s �, -��j PSARC/C�L$IZE L e <br /> OWNER NAME �. k K."`�'Gi PHONE <br /> OWNER ADDRF_SS J� CRYISTATFIZIP <br /> CONTRACTOR �LG IC-rrz—r Ur` PHONE <br /> CONTRACTOR ADDRESS {. CIrYISTATEIZIP <br /> i <br /> LICENSE 742 ❑C-36 OTHER NUMBER EXPIRATION DATE_ <br /> WATER TABLE DEPTH!_ 007 R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERT TESL' # BUILD[\G PERMIT# _ LAND USE APPLICATION f•' <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ E.NGINEFJt DESIGNED/ALTERNATIVE <br /> U REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> /NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -• ^ NUMBFROF EMPLOYEES: a� <br /> Id SEPTIC TANK TVPElMFG_ PJ✓ CAPACITY _� �/O gal #OF COMPARTMRNTS —2- <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE.TO NEAREST: WELL ft FOUNDATION � / _ It PROPERTY LME G—/ fl <br /> ❑ LIFT STATION SIZE _ TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCI.OSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS `�GZYI. J S #OF LINES LENGTH OF LINES Llo_ ft <br /> DISTANCE TO NEAREST WELL /45�D ft FOUNDATION R PROPERTY LINE J fl <br /> ❑ FILTER BED WIDTH __ft LENGTH R DLFni <br /> DISTANCE'r0 NEAREST WELL R FOUNDATION _ __ ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH A DEPTH ft <br /> DISTANCETONLAREST WELL ft FOUNDATION _ R PROPERTY LINE R <br /> Cl SUMPS WH7rH R LENGTH ft DErti <br /> DISTANCE TO NEAREST WEU. fl FOUNDATION _R PROPERTY LINE. ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH _ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION 11 PROPERTY LINE ft <br /> 1� SEEPAGE PITS NUMBER WIDTH (%— _A R DEPTH <br /> DISTANCE.TO NEAREST WELL,1QQ R FOUNDATION -IQ e, R PROPERTY LINE R <br /> I HERF.BV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THL WORK WILL RE DONE.IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES.STATE IAWS AND RULES AND REGLLATIONS OF SAN JOAQUIN COUNTY. <br /> MINIM U}t 24 HOLR Al1VANC CF:REQUIRED FOR INSPECTIONS-PLEASE CALL C09)953-7697 <br /> SIGNED TITLF �/V� DATE <br /> Jf <br /> ne <br /> i <br /> SL <br /> J <br /> W <br /> ) o <br /> DEPARTVIEN'f U'S ONLY })EAL-TH <br /> Application Acceptedr_�` Date ' �- Area Employee ID# <br /> Final Inspection �"-i Date y_ _ ❑ SPEC7A PERMIT-ApprovedbyCharacter of Snll PIt/Sump Soil Character: <br /> COMiy1EN FSI�n_y 1 M s•• <br /> PESC Received Chec Amouat Date Invoice# Permit ID# <br /> Code INPo B Cash Remitted Date R uest <br /> S v ? 6 ' <br /> I <br /> rs- <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12'222003 <br />