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ONSITE WASTEWr,`,4R TREATMENT SYSTEM I,..dtMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3M11 FL-"5'fOCKTON CA 95202 - (209)468-3420 <br /> NON-REFtINDAHLE PERMIT CA H,(209)953-7697 FOR INSPE 'TIONS F,XPIRES I YEAR FROM DATE ISSUED <br /> ,A y <br /> dun Ammusti q () r /�� _ <., ) CI'T'Y/'LIP- (C'd/ �//� t�•f <br /> t'ItOSS ti'I'ItF:F:i PN 23 —230 - 31— PARCEL SIZE W• y �vp <br /> OWNER NAME V 'Frei I(/� (} opyhyX�l�j �t�( ('i � /PHONE ���/1l� G��,(� <br /> OWNER ADDRESS ' (,•,� {�) CITV/STATE/ZIP Cot I l_ 1 L SIZ` Q y <br /> CONTRACTOR N'P/S' / -•�,! _¢ �SS PHONE V 37-3�, <br /> CONTRA(-1'OR ADDRESS CID�.�V1�,dVSj�1� 1 CIT%'/STATF./ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X V <br /> roll FERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDFNCE ❑ COMMERCIAL ❑ OTHER N <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: C, <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> I, <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTIAENTS <br /> ❑ PKC TX PLANT DISTANCE'r0 NEAREST: WELL Il FOUNDATION ft PROPERTY NE (Zej� .. r Oel! ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENG III OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION tl PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPT14 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH Il LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION Il PROPERTY LINE ft <br /> Cl SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH Il DiNGTH ft DEPTH n <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNS TITLE 6010(t%7 DATE <br /> J •� <br /> acd <br /> 71 <br /> �A4;AQ JIN <br /> M N <br /> DEPARTMENT V4E <br /> Application Accepted B Date 6 Area r Employee ID# <br /> 92- <br /> Final Inspection ,��. Date ❑ SPECIAL PERMIT-Approved by <br /> Character of So(ta Ah. 3 Ft: �,� Pit/Sump Soil Character: <br /> COMMENTS <br /> c)7 qO 7 <br /> PE SC Received ck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service Request# <br /> 42-OI-ODI <br /> 1212 IQ <br /> ONSITE WASTEWATER PERMIT <br />