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I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3"FL-S"McKTON CA;95202 -20468-3420 <br /> ~ NON-REFUNDABLE PERMIT CALL 209 1 1953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ';k. 60Lohe lrrc !� CMIZIP ECT g10T 9C�1A <br /> JOB ADDRESS //I-B <br /> ( CRoss STREET �J;"��V� '/�4/L/(� ee APIN joI)V-F� PAR�C[ELSIZE <br /> OWNER NAME T QWL �`�ItA`Y0. VCA✓ f4TOM0.1 MPlA'1 fY PHONE ary3U-1919 <br /> OWNERADDRESS I�J401Y1Q, {fiC_ Epp CITv/STATE21P p <br /> CONTRACTOR PHONE o 7" laa <br /> COnTMCTOCTTY/STATU74P •C- _ S7 4 <br /> L LICENSE ❑C42 0G3 OTHER A 9 QS NUMBER E%PIRATIONDATE <br /> N <br /> WATERTABLEDEPIH: R GeOORAPHICALINPOIIMATION: Coordinates X Y Ip <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPEOFWORK: ❑ New InSTAW.ATION REPAIp/ADDITION ❑ ENGINBERDESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ EVIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF <br /> LIVING UNITS: NUMBER OP BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPFJMFO CAPACITY Bel #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPF/MFO CAPACITY pl #OFCOMPARTMENTs <br /> ❑ PEG TX PLANT DISTANCETONEAREST: WELLit FOUNDATION ft PROPERTY LINE fl <br /> ❑ LIFT STATION SIzE TYPEOFPuM1P - ❑ SAN OILSEPARATOR(E M) <br /> L ❑ LEACH LINES ❑ LEACHING CHAMBERS NOF rvEs LENGTx OF LIN qO ft <br /> DISTANCETO NEARCBT WELL Ioa7J ft FOUNDATI N ft PRO, <br /> R <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH R <br /> r DISANCETONEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> II�R ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DIBGNCETONGRL4T WELL R FOUNDATION ft PROPERTY LME it <br /> ❑ SUMPS Wmrr ft LENGTH it DEPTH ft <br /> DwAracE To NEAREST WELL ft FOUNDATION R PROPERTYLME R <br /> L ❑ DISPOSAL PONDS WIMN R LErvOTtI R DEPTH ft <br /> DISTANCe ^G WELL / ft OUNDATHON ft PROPERTY LME R <br /> 13 SEEPAGE PITS NUMBER 9 WDJTH 3tl ft DEPOT S ft <br /> TO <br /> DIbTAN N WELL 3O FOUNDATION R PROPERTaY LME LX." ft <br /> O• <br /> 0� THEREBY CERTIFY THAT HAVE PREPARED THIS APPLICATION WORK WILL OF <br /> OACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATION90P BAN JOAQUIN COUNTY. <br /> TNI MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> LSIGNED TITLE DATE <br /> CAM IN O # <br /> F.4 Ilia III A�Z_F <br /> L <br /> ?MT%I <br /> L <br /> PARTMENT Sg1O 0Q <br /> Application Accep Me Z� Am EmployeelD# S 4 <br /> + FIRM Impaction By ate ❑ SPECIAL PERMIT-Appmvd by <br /> ChomcterM Sal to IN at Pt: P' Sump Soll Character: <br /> 7COMM NTS <br /> ,ZIP <br /> PE SC Received CheMW/ AnlDont Date PermiU Invoke# Permit IDN <br /> Code Im* B RemiHd Service Re ues[# <br /> L42-02-001 ONSITE WASTEWATER PERMIT <br /> IMMO0,11 <br />