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ONSITE WAS EWATER TREATMENT SY"�� ANNELP <br /> 304E WEBER AVE,M PESrpcicrON CA 95202 - (204)468-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT CALL z09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED r i <br /> CITY/ZIP <br /> M <br /> JOB ADDRESS j f <br /> APN �J PARCEL SIZE d <br /> CROSS STREET 1" <br /> PH <br /> D <br /> OWNER NAME <br /> CITYISTAT£IZIP <br /> OWNER ADDRESS <br /> d� PHONE <br /> CONTRACTOR <br /> ` d CITVISTATEIZIP <br /> CONTRACTOR ADDRESS - <br /> NUMBER EXPIRATION DATE <br /> kf LICENSE ❑C-42 ❑C-36 OTHER Y <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> ❑ L <br /> PERC TEST # BUILDING PERMIT# AND USE APPLICATION# <br /> ❑ ❑ ENCINEERDESIGNEDIALTERNATIVE <br /> -REPAIR/ADDITION <br /> TYPE OF WORK: ❑ NEW INSTALLATION d DESTRUCTION <br /> [J REPLACEMENT <br /> ❑ ❑ <br /> INSTALLATION WILL SERVE: ❑ COMMERCIAL OTHER <br /> RESIDENCE NUMBER OF EMPLOYEES: <br /> NUMBER OF LIVING KNITS: NUMBER OF BEDROOMS: <br /> ❑ SEPTIC TAMC TYPE/MFG <br /> CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG <br /> CAPACITY gal #OF COMPARTMENTS <br /> {� ft <br /> ❑ PKC TX PLANT DISTANCE Tp NEAREST; WELL FOUNDATION ft c PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP El SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ft V <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ft LENGTH ft DEPTH ft <br /> El FILTER BED WIDTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Z <br /> -LI MOUNDED WIDTH <br /> ft LENGTH ft DEPTH ft <br /> ' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft ' <br /> PROPERTY LINE ft <br /> (3 SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> L3 DISPOSAL PONDS WIDTH ft LENGTH DEPTH ft <br /> Ift <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft - <br /> i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> i I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY q <br /> ORDINANCES,STWE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, <br /> I MINI M 24 H R N NOTICE REQUIRED FOR INSPECTIONS-P E ALL(209)953-7697 D 7 <br /> i <br /> TITLE DATE <br /> SIGNEDIV C <br /> I <br /> I G U <br /> +1 <br /> ,iF N E <br /> AILPAt <br /> I <br /> O <br /> DEPARTMENT U E qNLV A r W <br /> Application Accepted By Date Z 7 Area Employee iD# �? e <br /> Final inspection By Date ©SPECIAL PERMIT-Approved by <br /> Character at Soil t e yo1F Ft. ` � 'I;�kSb*Soil Character: <br /> COMMENTS ' <br /> JV <br /> �. n <br /> PE SC Received hec Amount Date Permit) Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br /> l <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12122!2003 <br />