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i ;\t <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAH JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868E.HAZELTON AVENUE-STOcnoN CA 95205-(209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joa ADDRESS � .. y�e('adA <br /> A � Gr4 <br /> CROSSSTREET �fJ.P'!A _ APN T-0-3 PARCEL SIZE. =J,. F_ <br /> OWNER NAME PHONE <br /> 9 <br /> OWNER ADDRESS _I'M C, nw4er Cm/STATFRIP N _-Y__ <br /> CONTRACTOR_ �.e A:.Y-f CL�.,L. Ir _ PHONE. 0-'I+—y6 e- qT <br /> CONTRACTOR ADDRESS _ f U _LP�CI -._Cm/STATEZP <br /> LICENSE '!C-42 ',IC-36 OTHER_ NUMBER V Y%PIRATION DATE-i�1aLLt—_ <br /> WRIER TABLE DEPTH:__. 0 it GEOGRAPHICAL INFORMATION: C.oTdinate5 X Y <br /> E,; PERC TEST Nom` BUILDING PERMIT#- _.. LAND USE APPLICATION#.�_-_ <br /> TYPE OFWORK: NEW INSTALLATION REPANAADDrTWN ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM i DESTRUCTKIN <br /> INSTALLATIONWILLSERVE: ?ESIOENCE ❑ COMMERCIAL II OTHER <br /> IJUMBER OF LIVING UNR3: I NUMBER OF BEDROOMS:_. NUMO£ROFEMPLOYEES: <br /> SEPTIC TANK TYPFIMFG f— rnPAr.ly gal NOF COMPARTMENTS Q, ._......_.. ! <br /> O GREASETRAP TYPE/MFG � �..�H-_. CAPAI-ITY _ gal NOFCOMPARTMENTS <br /> DNITANCETONEAREST: WELL _- --V-W— it FOHNUATON -I';-' it PROPFRTY LINE 1{{3fi It <br /> ❑ LIFTSTATION SIZE TYPEOFINLIA ____ ❑ PKGTXPLART ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Gr LEACH LINES LEACHING CHAMBERS _ _._``- NOF LINES LENGTH OF LINES J. It <br /> DISTANCE TO NEAREST WELLy/1_�, It FOLINOATION_jC,6_1 .h PROPERTY LINE V'$ I It <br /> ❑ FILTER BED WIDTH it LENGTH_--_ft DEPTR___ }t <br /> DISTANCE TO NEAREST WELL _..._ It FOUNDATION h PROPERTY LINE .... It <br /> ❑ MOUNDED WIDTH __it LENGTH_ It DEPTHIt <br /> DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE it <br /> ❑ SUMPS WIDra ft LENGIH _ R DEPTH ft <br /> DISTANCE TO NEAREST WELL____ ____ it FOUNDATION N PROPERTY ONE It <br /> ❑ DISPOSAL PONDS WIDTH N LENGTH __- - h DEPTH _ It <br /> DISTANCE TO NEAREST WELLB FOUNDATION it PROPERTY LINE It <br /> V�SEEPAGE PITS NUMBER ;LF WIDTH (I _ I tt DEPTH_' __ R <br /> DISTANCE TO NEAREST WELL It FOUNRAHON .,�-{�._.. . N PROPERTY LINE H <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANOES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 26 HOUR ADVANCE NOTICE REQUIRED FOR INS <br /> �P <br /> ECTIONS-PLEASE CALL 209 953- S7 <br /> SIGNED_. TITLE. �'..f)n�-(.cGJfl:l� DATE <br /> h <br /> I <br /> 41 <br /> _ E V7 <br /> 7 E <br /> DEPARTMENT US LY LL ,( <br /> Application Acce y - _� - ^�'� Dale LCI I Area t ( ��_ij ELLDJoyee IDp -L.[e_t{b <br /> Final lnapeclio IY '/L- i Dale «' 1.1 SPECIAL PERMIT-Approved by <br /> Character of Soil to D PIT,of 3 FI: _ _ PI ump Soil Character <br /> COMMENTS <br /> PE Sc Received (ch6okjf. Amount Date penmV Invoice a ParmU IDa� <br /> Cods INFO 0 _M Remitted Service ReRUaBtN <br /> 42'N ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> d2i112 <br />