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ONSITE WASTEWATEr -REATMENT SYSTEM PERMIT a <br /> $AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT %041301E WEBER AVE-3"FL-STocxrDN CA 952009)968-3420 <br /> ON-REFUNDABLE PERMIT'J CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS '.'_ / J VUT CITY/ZIP AI' 'J <br /> CRO5SSTREEr /ML/Lf.L�CDR�� /�cL APN 001—OSO—O2— —"y� '>i <br /> 1� yly PARCEL SIlE �0n <br /> 6.E., ME <br /> ,L�LIA���.��1 LO4 U' S PHONE '^ <br /> DWNERADDRF35 -//'re^�1 �y CITYISTATEIZIP <br /> TTTCONTRACTOR ICJ (,, PHONE <br /> C7ONTRACTOR ADDRM tagooRbAI Tiy CITVISTATEIZIP <br /> LICENSECA2 13 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH:/O�S fl GEOGRAPHICALINFORMATION: CODrdl.00 X Y <br /> T❑ PERC TESTS) NU�ER LANDUSEAPPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIRIADUITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENTLlDESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL El❑ OTHER <br /> 7 NUMBER OF LIVING UMTS: /1 J NUMBER OF BEDROOMS: T ��.n NDMBEROFEMPLOVEES: <br /> SEPTICTANK TYPFIMFG( ms-e �W CAPACITY 1&20(5 8a1 #OFCOMPARTMENTS_ r <br /> J <br /> ❑ GREASE TRAP TYPE/MFG CAPACRY Sal� NOF COMPARTMENT- 00 r'f ftST <br /> WM <br /> PKG TX PLANT DISTANCE TO NEAREST: WELL /,00,r fl FOUNDATION ,J` R PROPERTY LINE 1a <br /> ❑ LIFTSTATION Sim TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENcLOSEDSVs1EM) <br /> ❑ LEACH LINES IL LEACHING CHAMBERSAt?) // NQF LMEs LErvcrx of LINES fl <br /> Du;TANCETONEARESI' WELL/rXTr It FOUNDATIDN �A R PROPERTY LINE�ID ' fl <br /> ❑ FILTER BED WIDTH ft LENGTH fl DEPTH ft <br /> D15TANCETONEAREST WELL fl FOUNDATION R PROPERTY LINE It <br /> ` MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION fl PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH fl <br /> DUITANCETONEAREYT WELL ft FOUNDATION fl PROmwi-INE B S <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH fl DEPTH IT <br /> ` DISTANCE TO NBARE WELL fl FOUNDATION ft PROPERTY LINE fl C <br /> ❑ SEEPAGE PITS WIDTH R LENGTH fl DEPTH ft V- <br /> DIWANCETONEAIU4 WELL ft FOUNDATION ft PROPERTY LINE ft <br /> L I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES <br /> STATE WS AND RULES AND REGULATIONS OP SAN JOAQUIN COUNTY. (� <br /> IN m A VANN,CCE�NO�TICE REQUIRED FOR INSPECTIONS PLEABE CALL QN)953-7697 <br /> SIGN IG lWV TITLE ( 6ef/— DATE <br /> or <br /> If Aew <br /> 6 <br /> EIf <br /> a ✓ <br /> p N <br /> DEPARTMENIF <br /> USF ONLY <br /> Applicetbn Ac Date Area Empl.y.ID#� <br /> Final Inspect nR ate �/y C5y 11 SPECIAL PERMIT-Appy edb I <br /> _Character Mf SMII w Dept of3 FU PH/Sump SMII Chmcter: <br /> COMMENTS 0 ld 7'—RF 2 <br /> PE SC Received A—U4 Date Permit/ Invoice# Permit lDp <br /> Code IrvFo B sh Remitted Servlce Re ueH# <br /> J <br /> E.. <br /> 42-0I-0DI ONSITE WASTEWATER PERMIT <br /> I7 <br />