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ONSITE WASTEWATER TREATMENT SYSTEM STEM PERMIT cA9szoz-czoe�asa sazD <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED w <br /> ' A`I CrrY1zP UP R I o <br /> JDB ADDRESS <br /> 14L#4 N R f l r•"'y (�� <br /> t,},IN.J� APN (4/O 7 0 PARCEL SIZE <br /> GROSS STREET �j,� �f ,y ���• �3�� I M <br /> OWNER NAME t"f\�LL1'PS f_Y1�1 <br /> sBLo H�`(• i 2 CrrYISTATEa1P L—C D <br /> OWNER ADDRESS <br /> 4.10 E: OML C�(7tNV19C)f }' itA,i�L PHONE 3 09 -03 3 r <br /> CONTRACT,, <br /> (,._ODI GA q s 14Q <br /> CONTRACTOR ADDRESS <br /> '-�Q1- VJ• O)flc rn ST• cliYlsTATEIZIP <br /> LICENSE QC-42 QC36 OTHE, <br /> NUMBER EYPLRATION DATE <br /> WATER TABLE DEPTH: R <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# �'I ��I <br /> ❑ REPAIRIADDIiION a ENGINEER DESIGNED/ALTERNATIVE <br /> TYPE OF WORK: ❑ NEW INSTALLATION u DESTRUCTION I <br /> ❑ REPLACEMENT <br /> ❑ COMMERCIAL D OTHER <br /> INSTALLATION WILL SERVE: RESIDENCE NUMBER OF EMPLOYEES: <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br /> GREASCAPACITY gal #OF COMPARTMENTS <br /> ❑ TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TWFJMFG <br /> DISTANCE TO NEAREST: WELL It FOUNDATION <br /> R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS <br /> #OF UNEs LENGTH OF LINES ft <br /> ft FOUNDATION ft PROPERTY LINE ft <br /> DISTANCE TO NEAREST VrELLIt <br /> C3 FILTER BED WIDTH It LENGTH R DEPTH <br /> DISTANCE To NEAREST WELL <br /> It FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> L1 SUMPS W— ft LENGTH ft DEPTH <br /> It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ElDISPOSAL PONDS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELLR FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1 MU�UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED__r TITLE COb�S1DATE J <br /> S <br /> 2 <br /> f <br /> d 6 <br /> DEPARTMENT US <br /> Application Accepted By Date Area Employee ID# 5� <br /> Final Inspection By Date C SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft f'iNSump Soil Character. {■�H C D <br /> COMMENTS >�I.—L�C �S 3 kl�i� " C> <br /> MAY 0 4 2x15 <br /> ^de INFO R BIS ChAmount <br /> Rem�tted Date yr <br /> Service RePerml uest# Invoice# Permit ID# N,OAQu��I COA <br /> 7 O" S / o�Qc) ENV 1R0 p,RTMER <br /> EALY►-I 0 <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 42-01 <br /> 1014/07 <br />