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I I r <br /> I, ( ONSITE W'-TEWATER TREATMENT SYSTEM PEP'`TT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL H )EPARTMENT 304 E WEBER AVE-3"°FL-! DN CA 95202-(109)468-3420 <br /> E <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 roll INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z -1 '1 -T' 1�1 L•.sn v� o �� Cr Y/ZIP_ 1 f . 1 .I� <br /> CROSS STREET l APN ? ',7 \ PARCEL SIZE <br /> v <br /> OWNER NAME r ' S �' ✓�- PHONE vim, <br /> OWNER ADDRESS t ^�✓ C'I o , P Q3 CITY/STATE/ZIP <br /> CONTRACTOR A.1:7 iT PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP l <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC-TEST # V BUILDING PERMIT# LAND USE APPLICATION#V <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 CAPACITY gal #OF COMPARTMENTS <br /> ❑, GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME R 1 <br /> I ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft J <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft J I <br /> ❑ FILTER BED WIDTH _ ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL _ R FOUNDATION ft PROPERTY LINE ft !_ <br /> ❑ MOUNDED WIDTH - R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft r <br /> I <br /> ❑ SUMPS- WIDTH it LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It :LENGTH - ft DEPTH ft T <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME R 1 <br /> 1 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 /> I, MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE r C '-}.� k� DATE 2 P <br /> I <br /> A ,f <br /> IF _ I <br /> f <br /> 4f LL 1 <br /> i <br /> / O <br /> S J A U <br /> A TM EN I <br /> III <br /> (;may !! DEPARTMENT USE LV <br /> Application Accepted By. I `C`�- Date f 2-12,1170S Area Employee ID# 4 oo o <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> I <br /> PE- SC Received Check#/ Amount Permit/ j <br /> .! Date Involve# Permit ID# <br /> Code INFO B Cash Remitted Service R nest# <br /> 42-02-001 - ONSITE WASTEWATER PERMIT { <br /> 12=003 <br />