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� lF <br /> ONSITE WAST"NWATEk TREATMENT SYST �I PERMIT,, NA gp <br /> F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 61--„HTMENT <br /> 1 304 E WEBER A-,_,23"FL-STO4 I1 a4 ° -3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> F01WINER <br /> ADDRESS v r" 7 Z <br /> ” �, ,� L CITY/ZIP _y <br /> OSS STREETr1r vy APN (f z m <br /> 2G-�U -- PARCEL SIZE .t <br /> -i- <br /> NAW942&/ — <br /> ME {J S PHONEi.(J- <br /> kOWNERADDRESS �j(J �� �i A1C i_ l 1 <br /> •\ C- <br /> CITY/STATE/Zip_ 1-1. <br />. CONTRACTOR bI to.-� ���, ,f • <br /> PHONE �j� - k <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> �G <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER <br /> ExPIRATI E <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> LA PERC TEST(S) NUMBER '7— LAND USE APPLICATION# <br /> TYPE OF WORK; ❑ NEW INSTALLATION ❑ REPAIR/ADDITION <br /> ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: <br /> NUMBER OF BEDROOMS; NUM1IBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY <br /> gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST; WELL ft FOUNDATION R PROPERTY LINE <br /> ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS ) <br /> #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL tt FOUNDATION ft PROPERTY LINE ft i <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft k <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH tt LENGTH tt DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL tt FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH_ tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE rt <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HERESY 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 /> MINIMUM 2-4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED .r � - �/ TITLE iiiE 0DATE l 7- <br /> t <br /> ell <br /> I <br /> IAMAQ <br /> 3y {ala. <br /> M-. <br /> e <br /> i.rt< hl <br /> , n <br /> 7' u <br /> N JC)),Qq IN O <br /> r n VI <br /> DEPARTMENT USE �LY <br /> Application Accepted Date r 3 Area Employee 11)# f/qj <br /> Final Inspection B Date _ © SPECIAL PERMIT-Approved by <br /> Character of Soil to e t of 3 Ft: F iWSurnp Soil Character• 1 <br /> COMMENTS <br /> PE SC Received C eck#! Amount Date Permit! InvoicA# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br /> 42-0I-001 <br /> 12,12/02 ONSITE WASTEWATER PERMIT <br />