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eNSfTN WAS�,WATER TREATMENT SYSTeP*M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L—ARTMENT 304E WEBER A� 3 FL-STOCKTO ` .p <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> L� <br /> JOB ADDRESS U,• y n r+G CITY/ZIP <br /> CROSS STREET �C AP "- �/'I 4�+'r'�r W <br /> � PARCEL�SIZE <br /> OWNER NAME i7.r37C-6c j <br /> i <br /> OWNER ADDRESS P.o. Gr', Z�r7 CITY/STATE/ZIP 1 In <br /> ! 5_z3c� <br /> CONTRACTOR V (t p�n__ --4,_ 1-11-VL �-t� PHONE 2,"i" ��' ��13 <br /> CONTRACTOR ADDRESS +�� i7Gy. Jil�jC' CITY/STATE/ZIP Cz'8—;/ 6.Q-/ <br /> E LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> I WATER TABLE DEPTH: ,) ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I PERC TEST(S) NUMBER ;✓ LAND USE APPLICATION# <br /> E TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: © RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL, ft FOUNDATION It PROPERTY LINE R n <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> r <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENG - I. tl O <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft wpy:7 ft <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH ft 1 1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft VV <br /> 0 MOUNDED WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft n\ <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft 1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE - <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH tt <br /> .DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br />' SIGNED TITLE S uruc�-� DATE <br /> 10 <br /> I I <br /> r <br /> i <br /> �c <br /> - - -_ - --- _- _ - ---D_E-PARTM_ T-USE-ONLY <br /> Application Aece ;dB Date Area Employee 1D,;:7Final Inspection By - DRte ! /� /O Cv ❑ SPECIAL PERMIT-Approved byCharacter of Soil toh of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �/��QC( a <br /> f <br /> PE SC RecelvW Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO &By ash Remitted Service Request# <br /> 1 : j 9190 oo s Z <br /> 42-01-001 <br /> .1212/02 ONSITE WASTEWATER PERMIT <br />