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ONSITE WASTT"ATER TREATMENT SYSTEM PE IT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE ENT 304E WEBER AVE-3RD FL-$TOCKT- 202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ,ALL 209 953-7697 FOR INSPLCTIONS EXPIRES 1 YEA FROM DATE ISSUED <br /> JOB ADDRESS �'� �-�Zt f�—� ,`.�.� CITY/ZIPS � �-�z.. c <br /> CROSS STREET r APN ✓iT�' I �/ �' PARCEL SIZE ,S✓� AcG p <br /> O <br /> C t y <br /> J�-T• 7 -7 <br /> OWNER NAME PHONE L <br /> OWNERADDRESS t? 'I L e' CITY/STATFIZIP <br /> CONTRACTOR �_� I ' I I At ��-�•�� � I � PHONE ' <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y i <br /> R] PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#04— <br /> TYPE <br /> 4-TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAnUADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION - Tl <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 #OF COMPARTMENTS <br /> ❑ PKC TX PLANT .- DISTANCE TO NEAREST: WELL R FOUNDATION It PROPERTY LME R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS - #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft s <br /> DISTANCE TO NEAREST WELL ft-FOUNDATION ft PROPERTY LINE ft ` <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft (` <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WmTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> I HEREBY CERTIFY THAT 1 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 DATE <br /> l <br /> L - <br /> •a <br /> �II <br /> T T a <br /> 6 t0 <br /> 5 T II I 20 <br /> I�I FRANg <br /> T -3 r' <br /> 4 22 <br /> 12 <br /> T12 <br /> 1I I I yR <br /> 13T L <br /> I <br /> n 23 za S_ <br /> - <br /> 28yz <br /> s 2 , NIR UI <br /> 7 <br /> f <br /> DEPARTMENT USE 9NLY y <br /> Application Accepted I Date He/x//,K- Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by 7 y <br /> Character of Soil to Depth of 3 Ft: PIVSump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#!i" Amount Date Permit/ Invoice# Permit IDN- <br /> Service Request# <br /> Code INFO By,- ash Remitted <br /> '17 Zz s. �I(SL) HLk,s.li) <br /> 42-02-001 _ ONSITE WASTEWATER PERMIT <br /> 1282/2003 - <br />