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//y �w=- <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQLIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3""FL-ST'OCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PER.NUT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSLFD <br /> JOB ADDRESS <br /> C:Ross 51'REE1 J�r/�/ APN 1 �` PARCEL SIZE �,J-- <br /> v <br /> OWNER NAME: i PHONE <br /> OWNER ADDRESS CI F)lSTA'TElZIP � <br /> CONTRACTOR PHONE <br /> CONTR-ACTOH ADDRESS , f7cr T-���� •/�J_ CITY/STATE/ZIP At C9/1, <br /> LICENSE Ll C-42 ❑C-36 OTHER NUMBER EXPIRATION DA'W <br /> WATER TABLE DEPTH: fi GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NI I A\D USEAPPLICATIoN t <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAiWADDITION ❑ ENCINEER DESIGNED/ALTF.RNaTIVE <br /> RKPI AC'EMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCLAI, ❑ OTHER <br /> NUMBEROF LIVING UNITS: NLMBER OI7 BEDR({OMS: NL'AIBER OF.EMPLOYEES: <br /> ❑ SEPTIC TANK TT PE%b{EG_ CAI'ACi'I Y _ gal 4 OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMF[l CAPACf[Y eal 4OFCOYIPARTMFNTS -- <br /> ❑ PKG TX PLANT DISTANCE TO NEARE.S?T: WELL ft FOU1'DATION ft PROPER I'),Lim: ft <br /> ❑ LIFT STATION SIZE Ti PE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SNSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS t'OF LINE) —_ LL101II OF LINES <br /> DISTANCE TO NE.ARES'I WELL ft FOLNDATIU\ fr PKOPER FY LINE tl <br /> ❑ FILTER BED WIDTH II LENGT]I ft DLPIH <br /> . t <br /> DISTANCE To NEAREST WELL _ ft r0liNDA'FION I[ PROPERTYLL`E _ fl <br /> ❑ MOUNDED WIDTH ft LENGTH l DEi'LIi <br /> DISTANCE TO NEAREST WELL _ ft FOIJND,,S710N Il PROPERTY LINL ft <br /> ❑ SUMPS WIDTH + fL LE GTH _ �� Z f[ DEL'IH � ft ^ <br /> DISTANCE TO NEAREST WELL t[ FOUNDATION ft PROPEK I Y LINE Ft <br /> ❑ DISPOSAL PONDS WIDTH I[ LENGTH ft DEPTH_ <br /> DISTANCE TO NEAREST WELL It F(IUNDATiON {L PROPERTY LINE Il <br /> ❑ SEEPAGE PITS WIDTH It LENGTH ft DEPTH fl M <br /> DISTANCE TO NEAREST WELL _It FOIi';DATICN' ft PROPERTY LINE tL <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORE:WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUN'ri,ORDINANCES, <br /> STATE LAWS AND RE;I.FS AND REGULATIONS OF SAN JOAQLTN COUNTY. <br /> IYI'MU N 24 )UR AD4 E N )TICE RFQIARED FOR IN'5PE:CTICINS—PLEASE:CALL(209)953-7697 � <br /> SIGNED s '� TITLE K ��C�,ClLr DATE <br /> �X — <br /> o a <br /> rN. <br /> i14t <br /> �� '_ H DEF ARM NT <br /> LJ DEPARTMENT l•S ONLY <br /> Application Accepted Ft Date i Area 'Z I Cf Gmployce IDu_ <br /> Final Inspection By_� I �t ' Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soli to Dcplhi f 3 Ft: Pit/Sump Soil Character: <br /> COMMLNTa I�_ f f r. rf su. .I .�ttzz7 L�� r.� (rt4S7 /`SC f<1y •t'V. vomit (,;� <br /> PE SC Received Check#! Amount —Pei'rrliff-.- <br /> Date Invoice# Permit ID# <br /> Code INFO BZn Remitted Service Request <br /> -42- r[ rrs l �' t C ' <br /> 42-of-OuI <br /> (I <br /> 11 2'02 NtiI I L WASTEWATER PERMIT <br />