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"'IVY ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />!! I SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEr -`ENT 364 E WEBER AVE-3"FL-STOrSCA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT L__—L(209)953-7697 FOR INSPECTIONS EXPIRES LAR FROM DATE ISSUED <br /> JOB ADDRESS 'W C' '>� CITY/ZIP �� sOY <br /> CROSS STREET' } ne APN V.�Zc3/�, 70 —� _ PARCELS[ZE ! ��"" > <br /> ^ f <br /> EEE OWNER NAME 470+^P� Y ]��`I.e.�S !! '�[d�� <br /> PHONE <br /> OWNERADDRESS CITYISTATEIZIP ?I1�, /f� ,p <br /> 'r-1VY <br /> o <br />' CONTRACTOR PHONE <br /> F', CONTRACTORADDRESS C[TYISTATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR]ADDI'TTON ❑ ENGiNEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ElRESIDENCE ElCOMMERCIAL ❑ OTHER <br /> k } NUMBER OF LIVING UNITS: NUNmxROF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPFJMFG CAPACITY. gal k OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> fTl`'" ❑ LEACH LINES EI DISTANCE <br /> CHAMBERS #OFLINES LENGTH OF LINES ft <br /> F! <br /> + DISTANCE TO NEAREST WELL ft FOUNDATION 'R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DER;rH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> F,J IDMOUNDED WIDTH ft LENGTH R DEPTH R �3 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft v <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft J <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCETONIAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> 1 ' <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> I DTSTANCETONLAREsT WELL ft FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY 4 <br /> 1 } ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. - <br /> NIM UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 / (� <br /> SIGNED TITLE CI'T-/T+z _. DATE J6'/s/�4 zJ ' <br /> 1 <br /> t <br /> Fi <br /> n <br /> 1 <br /> 4 <br /> i <br /> P � <br /> �n t <br /> DEPARTMENT US ON Y S <br /> Application Accepted By �C.i�/^�--�� Date 2I 7 Area �—I Employee ID# i"EQ /9, <br /> Final Inspection By ! Date 7i Sl ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to, Dom/of 3 Ft: Pit/Sump Soil Character:' COMMENTS J/-2 <br /> PE SC Received Amount ate Permit/ Invoice# PermitED# <br /> Code INFO B Cash Remitted Service Re uest# <br /> 2..14 bZ.S Cil b'e! <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22!1603 <br />