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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTML'M 3M WEBER AVE-3-PL-SEOCKTON CA 95202-(289)168-3020 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 7 L,A� ( MyPfS cO IZIP <br /> CHOSE STREET � '� APN /'.' l:2 PARCELSIZE ��^C C <br /> T-� O <br /> L.y�) ;.�M.<(Cr PHONE 2G97D2 -&/A( `ani° <br /> OWNER NAME Z11 }A <br /> OWN ER ADDRESS .1�A✓ '✓pA T:l 7V CITYISTATEAZIP 1,,A,Ar-4 L(J�./7 <br /> CONTRACTOH <br /> R , PHONEd� Y,7/IXjL. <br /> CONTMCTOR AODREB9 I.,ny� CLEAWATEIZIP .K O^ C S <br /> LICENSE ❑Ci2 ❑C-36 OTHER NUMBER EXPIMTIONDATT. <br /> WATER TABLE DEPTH: ft Y <br /> FERC TEST # I BeTPOeTCPERMIT 4YiG S Y: IA AND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPAIRLADMIUMN ❑ ENGINEERDEMCNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DEFTRUcPIcN <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMB ER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPFJMFO CAPACITY PI #OFCOMPAHTMENTE <br /> ❑ GREASE TRAP TYPFJMFG CAPACITY BnI #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DurANCETONEAIM: WELL ft FOUNDATION ft PROPDBUY LINE ft <br /> ❑ LIFT STATION Stu TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OFLINES LENGTH OF LINES ft <br /> DISrANCETONEAREST WELL It FOUNDATION ft PROPERTY LINE IT <br /> ❑ FILTER RED WIDTH ft LENGTH ft DEPTH It <br /> DETANCETONEAREET WELL ft FOUNDATION H PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH E DEPTH fi . <br /> DISANCETONEARFAT WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENDTH ft DEFiH t <br /> DISTANCEYONEAREST WELL It FOUNDATION R PROPERTY LME 0 <br /> ❑ DISPOSAL PONDS WlDrx ft LEWTH ft DEPTH ft <br /> DMANCETONEARFIT WELL IT FOUNDATION ft PROPERTY LINE 0 <br /> ❑ SEEPAGE PITS NUMBER WHOM R DEPTH ft <br /> DISTANCETONEAREBT WELL It FOUNDATION ft PROPERTY LME ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> / OR IrvANCESISTATE LAWS AND RULES AND REGULATIONS OP SAN JOAQUIN COUNTY. <br /> ' U0..ADVANCE NOTICE REQUIRED FOR INSPE T10NS-IPLF.ANF.ACALlCL'IZ0919534M) <br /> SIGNED TITLE , YGY A{7l DAT <br /> E.$--1'G 7 <br /> f <br /> Lk I <br /> M <br /> T o <br /> DEPARTMENT USE ONLY <br /> Appii<vtion AccePtd BY - /'--'- Date �/iv L ^" Area Employee IDb <br /> Finvl lnepectbn By Date ❑ SPECIAL PERMIT-Approved by <br /> Charvaer of Soil m Depth of 3 Ft: IN"..,Soll CAarectert <br /> COMMENTS <br /> PE SC Rettivd .ChaWl ' Amm�ot Perm1U <br /> Cede INFO B Cvvh witted DaM Service Rimmem,# Invoice# 7tID# j <br /> e2-02M1 ONSITE WASTEWATER PERMIT <br /> 12R24003 "1111111110 S <br />