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ezb Co <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-WOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS - CIT/�t'/L+P 6:„A� <br /> m <br /> CROSSSTREET APN �05 // _C PARCEL SIZE D v <br /> 0 <br /> a <br /> OWNER NAME r PHONE _ <br /> OWNER ADDRESS � ITY/STATE/ZIP � �I/V�! !'7�P-/�Z�� <br /> CONTRACTOR L- PHONE _ t7(p[ a�Dt— <br /> CONTRACTOR ADDRESS CtTY/STATE/ZIP <br /> LICENSE C-02 ❑C•36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAnUADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT O DESTRUCTION <br /> I INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL[, ❑ OTR <br /> HE <br /> T <br /> rrryyy NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: !� �T NUMBER OF EMPLOYEES: <br /> Lip SEPTIC TANK TYPE/MFG L CAPACITY (p,O ll gal #OF COMPARTMENTS <br /> /❑` CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> / al I <br /> LIPKG TX PLANT DISTANCE TO NEAREST: WELL /g29A FOUNDATION _ ft PROPERTY LINE /QO fl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> qe LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES 6.4 ft <br /> DISTANCE TO NEAREST WELL fl FOUNDATION f9--1— <br /> fl PROPERTY LINE/b ft <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME fl <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL FOUNDATION R PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER N WmTH QQ 'T�-I it DEPTH �5, R <br /> I <br /> DISTANCE TO NEAREST WELL 004 ft FOUNDATION /400I ft PROPERTY LINE � ft <br /> 1 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 ADV NCE.NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7647 <br /> SIGNED TITLE �lJ ���y� DATE O <br /> 7 � <br /> B <br /> laP j <br /> MW N E T <br /> M <br /> _. J_ _. -- <br /> _. _ ART ,, -Y- ._ <br /> Application Ac ted L. Date �' Area Employee ID# <br /> Final Inspection Date ❑ SPECIAL PERMIT-Approved by I/ <br /> Character of Soil to Dept of 3 Ft: Pit/Sump Soil Character: � A ems?`y <br /> COMMENTS <br /> �� _ _ <br /> PE SC Received Check#/ Amount Date PermIV C# Permit IDN <br /> Code INFO B Cash Remitted Service R ues <br /> Z ► <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1222/2003 <br />