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L • <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HGLTH DEPARTMENT 306EWEBERAVE-3—FL-SQCWYR,CA95202-(309)168-3620 <br /> NON-REFUNDABLE PERMIT l CALL1(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> y JOB ADDRESS I `-1 1✓ �'Ih AT. CF alp <br /> CROES STREET �� APN �' 7 - —/ PARCELSize - <br /> L OWNERNAME I PHONE <br /> OWNERADDRESS CTEVISTATFJZIP <br /> CONTRACTOR �S� l �{ /.,IS/r-OJ PHONE " -1 / L' <br /> L CONTRwCTORADDREES ; In !L / Y•n. ✓.t. CEEY/STwTE(LIP � C <br /> LICENSE ❑C42 ❑C-36 OT1ER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: D GEOGMPHICAL INFORMATION: Coors nate, X Y <br /> ❑ PERC TEST N BUILDING PERMIT It LAND USE APPLICATION III—It f Cf C- G=1-' 1 <br /> L TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR ADOrtN N ❑ ENGINEER DEMGNEDIALTURNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMB EROPLIVINGUNTES: NUMBER OF BEDROOMS: NVMBEROF EMPLOVLES: <br /> L ❑ SEPTIC TANK 1VPE/Mc CAPACrt Sal MOFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPOMFO CAPACITY gel N OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONEARENT: WELLR FOUNDATION ft PROPERTY LINE D <br /> L ❑ LIFTSTATION SITE TYPEOFPUMP ❑ SANDOILSEPARATOR(ENCLUXISPSYSTEM) <br /> ❑ LEACH LINES ❑ LEACHINGCHAMBERS #OFLINES LENOIHOFLINE$ ft <br /> DISIANCETONEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> L ❑ FILTER BED Wm'rll ft LENGTH ft DEPTH ft <br /> DLSTANCETONEAREST WELL FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH - ft LENGTH ft DEPTH ft <br /> DIETANCETONEAtEST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMP$ WIDDRft LENGTH A DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WHOTH ft LENGTH R DEPTH ft <br /> DVTANCETONEAREST WELL R FOUNDATION fl PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUIWIA Wlmx R DEPTH ft <br /> L DISTANCETONEARESI WELL ft FOUNDATION It PROPERTY ONE ft <br /> I HEREBY CERTIFY THAT I RAVE 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 4 HOUR ADVAN NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 12091953-7697 / <br /> SIGNED 1 ^— A % TITLE v . �� !CC GATE <br /> L _ <br /> LI <br /> L - , E <br /> A <br /> P W <br /> M <br /> i <br /> Y - <br /> L <br /> y /J�`— DEPARTMENT USE ONLY <br /> Appllcatkn A.Pteal BY--"4, <br /> Y — r l/ Dale �� C 1 Ara EUNPIOYa IDN <br /> Heal Impeelbn BY .,_Date ❑ SPECIAL PERMIT-Appro.cd by <br /> Chander of all to Depth 9f3 FF. PIHSump 5911 Character: <br /> LCOMMENTS. <br /> L PE Sc Revived 11111 1110 Ameuit PermB/ Invoke# PermitlpN <br /> COEe INPO B "-Cath RemlHed Doh Sere" WHEN <br /> ONSITE WASTEWATER PERMIT <br /> 63-113-ODI <br />