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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SANlOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304EWEBERAvE-3"'FL-STOCUTONCA95202 (209)4683420 <br /> S <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM <br /> �JDATE ISSUED <br /> JOB,ADDRESS 2.21 b e : e[I L 7 9 �) CITY,I/ZIIP <br /> ` CROSSSTAEET FT^/,P ,"�J APN 4/�-�- ©r^' PARCLLSIZE �� o <br /> { �p�� <br /> BWNERNAME F-'VAF_-4PHONE <br /> OWNERADDRESS 31 a— -S u_,v.0 4,-)Com- CITYISTATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS _ CITYISTATEIZIP _ <br /> LICENSE ❑C42 Cl C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: fl GEOCRAPHICALINFORMATION: Coordinates X Y <br /> ❑ <br /> FERC # BUILDING PERMIT 4V LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATTON ❑ REPAIRIADDITION ❑ ENCINEERDESIGNEDIALTERNATIVE <br /> _ "�''CGE-❑ REPLACEMENT ❑ DESTRUCTION <br /> i INSTALL T N WILL SERVE ❑ RLSIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> I ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> F ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE R <br /> . ❑ LIFT STATION SIzE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES A N <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft N <br /> ❑ FILTER BED WmTx ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft °C <br /> ❑ MOUNDED WIDTH It LENGTH A DEPTH ft <br /> DISTANCE TO NEARESr WELL ft FOUNDATION It PROPERTY LINE ft , <br /> 0 sumps WIDTH R LENGTH ft DEPTH ft <br /> 1 DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft _ <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft r <br /> DISTANCETONEAREST WELL ft FOUNDATION it PROPERTY LINE ft Ll <br /> O SEEPAGE PITS NUMBER WIDTH fl DEPTH ft t <br /> F, DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I 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. L <br /> ILII ' 24 HOUR ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(269)953-7697 <br /> 1 1�/1 A <br /> SIGNED f !`l e _NI11161 TITLEDATE 6 <br /> k <br /> I <br /> I <br /> lit H IIEF kRjM4N <br /> I LJ <br /> DEPARTMENT U,E ON Y -7 37 <br /> Application Aece d Date S U- Arca Employee IDN �J <br />{ Finallnspection _ Date �� ❑ SPECIAL PERMIT-Approved 6y <br /> Fj` Character of Sail to D Ih oT 3 Ft: P111sump Soil Character: <br /> 1. COMMENTS +CT pF- SrEi—vIC S P06-6-177-71 VEL I F QST f F SE <br /> `�,:� (g ���C�,g� �0 2 �"�c-e.c�" ;��G�•r�Grp d Za.C3Gs!it/Gly <br /> PE EINFO <br /> Received Amount Date Permit! invoke# Permit[D# <br /> Code B s Remitted Service Request N <br /> zb o� JO Iaa.rT� S b ? J <br /> Aa-' ezw=A'&O" «� I ONSITE WASTEWATER PERMIT <br />