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i <br /> ONSITE W< -EWATER TREATMENT SYSTEM P NIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-,rockToN CA 95202-(I09)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM D E ISSUED <br /> C� CITY/'ZIP / L <br /> JOB ADDRESS _ <br /> a <br /> CROSS STREET _ 1� �"' / APN CJ&-3— 00-37 PARf.F.1.S17.F. 9•a� o <br /> OWNER NAME • '�r Uh C7 CA r -� PHovF — <br /> WNER ADDRESS , /STATEYZIP _ <br /> i <br /> CONTRACTOR PHONE <br /> fv' <br /> CONTRACTOR ADDRESS l ' ` C Y/STATEIZIP -� <br /> LICENSE ❑C-42 ❑C-36 OTHER NU ER EXPIRATION DATE gj <br /> WATER TABLE DEPTH:_ it GEOGRAPHICAL INPORMAT : Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER_ LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAINADDITI N ❑ l�'NGINEER D^EeSI`GNED/ALTER ATIVE <br /> ❑ REPLACEMENT DESTRUCTION f7t <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIA ❑ OTHER <br /> NUMBER OF LIVING UNITS:_ NU NEER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gel #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETONEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft Q <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 It PROPERTY LINE ft <br /> ❑ FILTERBED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH _ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION_ R PROPERTY LINE ft <br /> J SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION_ it PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH_ It DEPTH B <br /> DLSTANCE TO NEAREST WELL ft FOUNDATON ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION n PROPERTY LINE ft <br /> 1 I IE REBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMU OUR VANC' CE REQUIRED FOR INSPEr,l'O '-PLEASE C )953.7697 <br /> Ftfly /� �'3 <br /> -3!41GNFDv _ 1'1'FLE UAT <br /> t <br /> IVIA <br /> Pr <br /> i <br /> r <br /> { <br /> ti <br /> EP,IRTMEN USE NLV 1 <br /> Application Accepted Rv Date 3 Area Employee ID#_ <br /> Final Inspection PAIC,,:�j Data /t'�!L ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil W De of 3 Fe _ Plt/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount P It/ <br /> Code 1, <br /> FO 13as Remitted Ualc ery Invoice# Permit ID# <br /> �) 75 S 15?Y— Il R �j a3 <br /> 42-01-001 <br /> 12/2102 ONSITE WASTEWATER PERMIT <br />