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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3D4E W¢11LR AV¢.-3°O Fl.-STOCKrON CA 95202•(Z09)J6g-UED <br /> NON-REFUNDABLE PERMIT CALL�(209)9M-7697 FOR INSPECTIONS EXPIM I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Cm21P <br /> oc <br /> CRO53 STR¢ET �- >ry �J APN �dS— l(ro-ID PARCELSI= �' j <br /> - <br /> if/I/J S PHONE Z.l. r� /12 ' <br /> OWNERNAME <br /> CITY/STATE/ <br /> OWNER ADDRESS LP /- - <br /> PHONE <br /> CONTRACTOR <br /> LM/STATE/ZIP <br /> CONTRACTOR ADDRESS <br /> LICENSE 42 ❑C-36 OTHER NUME[R E%PIRATIONDAT¢ <br /> WATfRTABLE DEPTN: <br /> ft GEOGRAPHICALINFORMATION: Cwdium X Y <br /> 0 PERCTEST % BUILDINGPERMIT# LAND USE APPLICATION# <br /> R¢PAIP/ADDITION O ENGINEER DPSIGNED/ALTERNATIVE <br /> TYPE OF WORK: ❑' NEw INSFALwT1oN DrsTRurnoN O-LZ <br /> REPLAcMERr <br /> INSTALLATION WILL SERVE: AD RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OP BFLROOMS: �� NUMSEROPEMRAYEES: <br /> NUMBER OP LIVINGUNITS: <br /> SEPTIC TANK TYPE/MFG N E f CAPACITY /��O�J EAI %OFCOMPARTMENTSLl <br /> (3 GREASE TRAP TYPE/MFG CAPA, gal koFCOMPARTMENTE <br /> ❑ PKG TX PLANT DISTANCCTO NEAREST. WELL ft FOUNDATION <br /> R PROrERTY LME ft <br /> ❑ LIFT STATION SIPS TYP[OFPUMP ❑ SAND OIL SEPARATOR(ENCLOS[)SYSTEM) f <br /> l J/ ft 'V, <br /> LEACH LINES ElLEACHINGCHAMBERS koF LrtlEs� i-¢NGTH OF Lines � R � <br /> DISPANC¢TO NCARPST WELL Q// R FOUNDATION Y ft PROPERTY LIFE uJ <br /> It DEPTH R <br /> ❑ FILTER BED WIDTH ft LENGTH <br /> R PROPERTY LMER r I <br /> DIbTANCE TONGRLbT WELL fl FOUNDATIONft <br /> ❑ MOUNDED WmTN ft LENGTH ft DEPrx <br /> R <br /> DISTANCE TO NLAREST WELL R PROPERTY LME ft PoVNDAi1pN � fl <br /> ❑ SUMPS Wlmx ft LENGTHft DEPTH <br /> DISEArvC¢TO NEAREST WELL fl FOUNDATION ft PROPESTY LME fl <br /> R DEPTH <br /> ❑ DISPOSAL PONDS WITH R LENGTH <br /> DISTANCETONLAAF� ELwmTH?i��WL R FOUNDATION <br /> R <br /> R PROPERTY LINE R <br /> fl DFArx _I <br /> SEEPAGE PITS NUMBER�_ <br /> DISTANCETO NEAPPST WELL //b�2 R FOUNDATION //YJ�' R PROPERTY LMe <br /> I HEREBY CERTIPYTFIATI HAVE <br /> PCES.STATELAWS WITH SAF;JOAQUIN COUNTY <br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY' <br /> E <br /> MINIMUM24/`URADV CE NOTICE REQUIRED FOR INSPECTIONS-PLLEE'ASSE1CALL(209)953-7697 <br /> SIGNED TITLE L/L V DATE <br /> k <br /> 1 <br /> O M <br /> DEPARTMENT UFX ONLY Empl <br /> Appliatlov «epMd C""'-- DuvU 4 ec- Aree <br /> Flvvl lvtplxtlo D.W ❑ SPECIAL PERMIT-Appmvd by <br /> Cluncwrof SoilwDe of3FO PitlSamp Soil Chnuwr: <br /> COMMENTS <br /> PE Sc Raelvd Anwov[ w PermlU Invoice% Permit lD% <br /> Code INFO B Ch Remitted ServittRmIHSx# <br /> / <br /> 2.10 Wr 230-rA� <br /> ONSITE WASTEWATER PERMIT <br /> 62-024U <br /> ILZ3/200] <br />