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ONSITE WASTEWATER TREA1�TMENT SYSTEM PERA CANED <br /> SAN JOAQUIN COUNTY ENVIRONMENTF <br /> AL HEALTH DEPARTMENT ' 304E WEBER AYE-3-FL-STocKON CA 95202-(209)44&3430 <br /> NON-REFUNDAB E T C 209 953.769. INSPECTIONS EXPIRES 1 VEAR FR M ISSUED <br /> Jos ADDRESS w 1 CITYIZIF <br /> CROFSSTREET NY APN I PARCELS.. • > <br /> OWNERNAME PHON <br /> OWNER ADDRESS CITYSSrATEYLIP <br /> DACONTRACTl1R / Pxory <br /> CONTRAGI'OR ADDRESS / Cal IS7'ATFlLIP U <br /> LICENSE C42 ❑C-36 OTHER NUMBER 7 RATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: CDBrdlaales X Y <br /> ❑ PERC TEST M I i BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPEOF WORK: ❑ NEW INSTALLATION Q REPAIRfADamOn CJ ENGINEER DESIGNED IALTERNM1TIVE <br /> �x� ❑ REPLACEMENT' �' DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ S£PTICTANK TYPEIMPO CAPACITYgal M OF COMPARTMENTS <br /> ❑ GREASETRAP TYPEIMFG CAPACITY gal MOF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONEAREST: WELL R FOUNDATION ft PROPERTY LINE R <br /> Q LIFTSTATION SIZE -TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES O LEACHING CHAMBERS MOFLINES LENGTH OF LINES ft <br /> DISTANCETONEAREST WELL ft FOUNDATION fl PROPERTY LINE R <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH R <br /> D15TANCETONEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH 'I fl LENGTH R DEPTH R <br /> DiSTANCETO NEAREST WELL ft FOUNDATION -R PROPERTY LINE, R \ I <br /> ❑ DISPOSALPONDS WIDTH ._ fl LENOTH - - ft DEPTH R P <br /> DISTANC[TONEAREST WELL R FOUNDATION R PROPERTY LME ft 1 <br /> ❑ SEEPAGE PITS NIIMB[R W— ft DEPTH It \ <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE R .` <br /> I HERESY CER7IFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> }�ORDMANCM STATE LAWS AND RULES AND REGULATIONS O USAN JOAQUIN COUNTV- 1 <br /> IN�3(1 V CE NOTICE REQUIRED FOR I NS-PL L(2091953-0147 <br /> S1GNE A TITL DATE <br /> C <br /> IV HEA <br /> D <br /> I <br /> DEPARTMli7Y,T USE ONLY <br /> AppllaHon epM _ DR1N �9�Q� Area Employ«ID I <br /> Final lDapecik By DRte 4IL2106 Q SPECIAL PERMIT-Approved by <br /> Chander 19.41 1.De th o!3 FI: PitlSunLp SBH Char.Nrr: <br /> COMMENTS z6 ' <br /> PE SC Received CheekMl AmouRl Permitl <br /> nde INPo B ash Remitted D.I. ServiceR uestM luvokrM PrrmillDM <br /> U 7 C -co <br /> J2A2A01 ONSITE WASTEWATER PERMIT <br /> 12!1272003 <br /> I <br /> 1 <br /> a 1 <br /> .I <br /> 4 <br />