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la "o <br /> ONSITE WASTEWATI'R TREATMENT SYSTEM P �"' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"F 09)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 20 953-7697 FOR INSPECTIONS ' F <br /> EXPIRES I YEAR FNWR DATE ISSUED <br /> JOB ADDRESS �a S'sU "V jl rr� CITY/ZIP <br /> CROSSSTREET 41 /fe e a APN �_ � PARCELSIZE O'/ > <br /> 0 <br /> OWNER NAME D1,e- ZiIG/G Y✓• PHONE <br /> m <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR CA-N' ✓/}[L G PHONE .T S'- S�C� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C42 ❑C-36 OTHER NUMBER ys")Ot S EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I I BUILDING PERMIT# Z LAND USE APPLICATION# — L <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG LON//CIC /S-4— CAPACITY A100 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> c I <br /> Ll PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION r'J ft PROPERTY LINE 7 O R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> X FILTER BED WIDTH a/1 y ft LENGTH 3 9 I R DEPTH /19 11 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 3� ft PROPERTY LINE s' ft <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,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 T v/t DATE <br /> 5 <br /> I Ana <br /> m <br /> u, I <br /> 1 <br /> n <br /> R N E <br /> y1AtF <br /> +—## �j 11 %.1- 11 —fi EPARTMENT SE�- <br /> Application Ac pled Date Area Employee ID# <br /> Final Inspection - .<-�-'�' Date /<���(C�CJ�❑ SPECIALyPERMIT-Approved by <br /> Character of Soil to Depth f 3 Ft: - Pit/Sump Soil Character: /E i <br /> COMMENTS <br /> �:f <br /> PESC Received .may- •-'', Amount Permit/Code INFO B 2 -SSWDate Date Service Request# Invoice# Permit ID# <br /> SW,' <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12'222003 <br />