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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3`°FI,- <br /> NON-REFUNDABLE PERMIT STOCRTONCA95202-(209)468�4Jp <br /> TALI. 209 9531-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOD ADDRESS _ <br /> ---`�— CITY/ZIP � <br /> CROSS STREET _ S 1 N APN C b--,26� —1jIZ• ' <br /> PARCEL Zr fT•�U 1 <br /> OWNER NAME <br /> PHONE <br /> OWNER ADDRESS ig <br /> CITYISTATEM[P <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS Q I <br /> CITY/STATE/7,1p <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMEER <br /> WATER TABLE DEPTH: GEXPIRATION DATE <br /> fl EOGRAPHICAL INFORMATION; Coordinates X <br /> ❑ PERT TEST #_ Y <br /> — <br /> BUILDING PERMIT► LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NF.W INSTALLATION ❑ REPAIR/ADDITION <br /> ❑ REPLACEMENT ❑ ENGm'iEA❑ DESTRUCTION DESIGNED/ALTERNATIVE <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER <br /> ❑ <br /> NUMBER OF LIVING UNITS: .NUMBER OF BEDROOMS: <br /> NUMBER OF EMPLOYEES; <br /> ❑ SEPTIC TANK TYPFIMPG_ CAPACITY <br /> ❑ GREASE TRAP TYPE/MFG _ Sal #OF COMPARTMENTS <br /> CAPACITY gal NOF COMPARTMENTS <br /> ❑ LIFT STATION SIZE <br /> 13 PKC TX PLANT DISTANCE TO NEAREST: WELL fl FOUNDATION <br /> 11 PROPERTY LINE ft <br /> . TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS NOF LINES <br /> LENOTII OF LINES ft <br /> DISTANCETONEAREST WELL fr FOUNDATION \ <br /> 13FILTER BED WIDTH It PROPERTY LINE A <br /> [i LENGTH ft DEPTH <br /> DISTANCETONEAREST WELL ft FOUNDATION fl ~ <br /> O MOUNDED WIDTH — fr PROPERTY LINE ft <br /> R LENGTH f[ DEPTHIDTH R <br /> DISTANCE TO NEAREST WELL 11 FOUNDATION ft <br /> ❑ SUMPS W LENGTH fl PROPERTY LINE—_ft <br /> fl DEPTH <br /> DISTANCETO NEAREST WELLPROPERTY LINE ft <br /> ft FOUNDATION' fl `_fl <br /> Q DISPOSAL PONDS WIDTH_(1 LINCTH <br /> it DEPTH R <br /> DISTANCE TONEAREST WELL R FOU`DATION <br /> ❑ <br /> R PROPERTY LINE—_ft SEE PAGE PITS Nunlaea WIDTH <br /> ft DEPTH <br /> DISTANCE TO NEAREST WELL ft <br /> It FOUNDATION R PROPERTY LINE <br /> ft <br /> HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE IVORK W[LL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUMa HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> i <br /> SIGNED TITLE .�.-o„�i� v <br /> I�-F✓ DATE <br /> r <br /> J <br /> QXP RTMENT US NL' <br /> Application Accept Date <br /> ATea Employee IDN > � <br /> Flnal Inspection By Date lam/ <br /> Character of Soll to Depth of 3 t: ❑ SPECIAL PERMIT-AppToved by <br /> COMMENTS Pit/Sump Soil Character. <br /> PF. SC Received Check#/ Amount <br /> Code INFD g ay Date Permit/ <br /> emitted S Ic a uest Invoice N Permit IN <br /> 42-02-001 <br /> 1222 200} ONSITE WASTEWATER PERMIT , <br /> r� <br />