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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-S70CKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLEqPERMIT I CALL 209 953-7697 FOR INSPECTIONS p EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _1-?-II`e}�,�V wF- Z - <br /> ' CITY <br /> P ^A-Cy I <br /> CROSS STREET � Al2 — APN 2��- D� - PARCELSIZE -� A b <br /> p�� 4 v <br /> OWNER NAME L ✓�p��`-pItjEZ" !� �TPHONE ZZ� `n- <br /> OWNER ADDRESS �21 /w - w .071 �,J CITY/STATE/Zip A ��'-jCA <br /> CONTRACTOR L'IJ6 //d,'PGK' l7LoEjL/)/eC"�m��AL PHONE 3(Dc? -03�'S G <br /> CONTRACTOR ADDRESS 4& W- O A `��- CIN/STATE/Z1P L-V D I CR 1:f7S-2-4C5 <br /> LICENSE ❑C-42 ❑C36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> �( PERC TEST # l BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDrnON ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT Ei DESTRUCTION <br /> I NSTALLATION 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 /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft 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 WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION It PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> I HEREBY CERTIFY THAT I 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 /> INIMUM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE �NS�L I�^J T DATE -3- Zj'-1-7 <br /> ot <br /> I AN <br /> TF <br /> I <br /> 11 <br /> L <br /> �D ARTMENT NL <br /> Application Accepted By D to Area Employee ID# <br /> Final Inspection By Date ❑ $PE 'ALP MIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received k#/ Amount Date Permltl Invoice# Permit ID# <br /> Code INFO Cash I Remitted n( Service Re uest# <br /> -"I-10 <br /> ��n+ nMQITF INACTPWATFQ TQTMNT CV.CTFM PFRMIT <br />