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.—T6.• ONS ITE VI ASTEWATER TREATMENT SYSTEM Pi..<MIT <br /> T6 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AYE-3`b FL-STockwN CA 95202-(209)468-34121) <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR I NSPECTIONS EXPIRES 1 YEAR FROMDATEISSUED <br /> JOB ADDRESS d• CITYIZIP IV1 C S33 M <br /> P <br /> I� <br /> CROSS STREET � ECAPN I k moY/h::W PAARCEL SSIZE,;� <br /> OWNER NAME PH-0-NE� <br /> l-6Z�S�KI <br /> OWNER ADDRESS 1 m� CffVMTATVZIP <br /> CONTRACTOR i C� PHONE 26,1-710s <br /> CONTRACTOR ADDRESS CrrV/STAT1EJZIP <br /> LICENSE O C42 ❑C-36 OTHER M NUMBER O ExPiRAmN DATE P <br /> WATERTABLEDEPTH: ft GEOGRAPHICALINPORMATION: Coordinates X Y <br /> ❑ PERC TEST N BUILDING PERMIT# 0 LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIRIAODITION O ENGINEER DESIGNEDIALTERNA'CIVE <br /> ❑ REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ArZGMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ,/ NUMBEROF BEDROOMS: BEROF EMPLOYEES: <br /> SEPTIC TANK TYPFJMFG�fYVC fr GLS CAPACrrY 17-La gal NOF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY p! N OF COMPARTMENTS <br /> ❑ PKC TX PLANT DIBTANCETO NEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> O LIFT STATION sizE TYPE OP POMP O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES XLEACHING CHAMBERS p OF LINES_ LENGTH OF LINES 10 0l ft <br /> DIsrANCETONEAREST WELL O ft FOUNDATION fI PROPERTY L! ft <br /> 13 FILTER BED WIarH ft LENOTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> L3 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNT7ATION ft PROPERTY LINE ft <br /> C3 SUMPS WIDTH ft LENGTH fl DEPTM ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br /> MsTANCETONEARPST WELL R FOUNDATION it PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER Wwm ft DEPTH ft <br /> DisrAmccTONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CER THAT r HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCE$STATE LES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN MU 24 'ONCE NOTICE REQUIRED FOR INSPECTIONS-PI.F.ASE CA1.1.1Nl9i 953-7697 <br /> SIGNED TITLE DATE ' <br /> I <br /> 1 <br /> r <br /> V IF <br /> EZ <br /> or <br /> � E <br /> i <br /> N IE <br /> 1 <br /> .. DEPARTMENT SE O .-.�. <br /> Application Accepted By12:3 MI <br /> DNe Area Employee IDN q� <br /> PLnnL Innpection By Dale 1 ❑ SPECIAL PERMIT-Approved by i <br /> Cbaraeter of Soil to th or 3 FI: III Soil Character: <br /> COMMENTS <br /> PE SCReceived CbeckNJ Amount pate Service N Permit IDN <br /> Code INFO B as Remitted Service Request N <br /> 42-02.001 ONSITE WASTEWATER PERMIT <br /> 1241211003 <br />