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ONSITE WA'!-�,WATER TREATMENT SYS' M PERMIT �. <br /> 304 E WEBER AVE-3"°FL-STO - NC 52 ( 9) -3420 <br /> SAN JQAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NON-REFUNDABLE COUNTY <br /> PERMIT CALL 209 953-7697 FOR INSPECTIONS pEXPIR I R A SSUED 'LA I <br /> 9. CITY/ZIP <br /> JOB ADDRESS - > <br /> rr - APN _ '5 PARCEL SIZE_ -'I lJ ✓ _ !, <br /> CROSS STREET V e r (— �'] Gas <br /> PHONE tt �!'l. s <br /> NAME <br /> OWNER -,Jr� q � �� <br /> ` !'e [ &� CITY/STATE/ZIP LOGL'' �13fA, o <br /> f� o ti�w4.� <br /> t OWNER ADDRESS 0 <br /> PHONE '* <br /> � CONTRACTOR �'� ��-� -'v � <br /> CITY/STATE/ZIP J <br /> CONTRACTORADDRESS <br /> LICENSE ❑C-42 ❑C-36 OTHER • A it _ NUMBER ro <br /> EXPIRATION DATE <br /> Y <br /> WA'1'F,R•FABLE.DEPTFI: R- GEOCRAPt1lCALINFORMA"I70N: Coordlaates X �« <br /> L, FERC TEST # I7�'— 71+>t BUILDING PERMIT# <br /> LAND USE APPLICATION# l�l <br /> ESV—INSTALLAT[ON ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> TYPE OF WORK: - — ❑ DESTRUCTION <br /> ❑ REPLACEMENT <br /> ❑ COMMERCIAL. ❑ OTHER <br /> INSTALLATION WILL SERVE: RESIDENCE NUMBER OF EMPLOYEES: <br /> I <br /> NUMBER OF LIVING UNITS: ,•�"'�� . <br /> NUMBER OF BEDROOMS: <br /> CAPACITY gal #OF COMPARTMENTS <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG <br /> ❑ PKC TX PLANT DISTANCETO NEAREST, WELL �._ <br /> ft FOUNDATION R PROPERTY LINE <br /> El LIFT STATION 5[zE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSi D SYSTEM) <br /> ` #OF LINES LENGTFI OF LINES 0' <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS ft PROPERTY LINE <br /> DISTANCE TO NEAREST WELL ft FOUNDATION <br /> ft DEPTH <br /> ❑ FILTER BED WIDTII <br /> ft LENGTH ft <br /> #- ft FOUNDATION (Z PROPERTYLINE <br /> D[STANCEToNEAREST WELL ft <br /> ft <br /> ❑ <br /> MOUNDED Wm7'EI ft LENGTH DEPTH ft <br /> ft <br /> ft FOUNDATION PROPERTY LINE <br /> D[57'ANCETONEAREST WELL ft <br /> tl LENGTH ft DEPTH <br /> L1 sumps WIDTH ft <br /> ft FOUNDATION ft PROPERTY LINE <br /> DISTANCE To NEAREST WELL it <br /> 1t LENGTH ft DEPTH <br /> ❑ DISPOSAL PONDS WIDTH ft PROPERTY SINE ft <br /> DISTANCE'rO NEAREST WELL tt FOUNDATION <br /> it oEPrH <br /> ❑ SEEPAGE PITS NUMBER WIDTH <br /> � <br /> DISTANCE TO NEAREST WELL. <br /> ' ft FOUNDATION ft PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN,CQUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MI M UR ADVANCI-;NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(/P2-09)953-7697 <br /> I'17'LE 3 4C�t� DATE r <br /> SIGNED <br /> i C <br /> e— <br /> J1 <br /> i <br /> 'Jul <br /> DEPARTMENT US . - <br /> ON Y LIL Ci <br /> Date f i?� Area Employee ID# <br /> Application Accept <br /> Date ❑ SPECIAL PERMIT-Approved by <br /> Final Inspection <br /> Pit/Sump Soil Character: <br /> Character of Soil to Depth of 3 t: <br /> COMMENTS �� -7 <br /> PE SC Received Check#/ Amount Permit! Invoice# Permit ID# <br /> DatcServiee Re Dest# <br /> Code INFO B Cash Remitted <br />