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ONSITE WASTEWATER TREATMENT SYSTEM PERM17jL, axo I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � 304E WEBER AVE-3 FL-STOCkrO <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1�YEpAR FFR D7A/TE�ISSUED <br /> JOB ADDRESS II Y�'D W./ "« CITY/TdP I ftp ? ^ / /Y y <br /> CROSS STREET Ol'/, � j��0/v >��� APN �2 b G �JP�A�RpCEL SIZ2E ��p� o <br /> OWNER NAME 24�&.Y l�a 'T .ZYC-�1.C� /i(mac-��GLi1r7 PHONE�Ci(//T <br /> OWNERADDRESS ��QJ kll, R• CITY/STATEtZIP j rflCy lc—� S)'37<,O <br /> I <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATFIZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAHUADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> �[ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> lLT SEPTIC TANK TYPE/MFG CAPACITY gdl #OF COMPARTMENTS j <br /> /❑ GREASE TRAP TYPF/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINESLENGTH OF LINES ft <br /> �J DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> AL <br /> FILTER BED wroTR iia ft LENGTH DEPTH i R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION D ft k*4-PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HO ANCE NOTICE REgUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7647 <br /> SIGNE L TITLE DATE <br /> TA <br /> I <br /> 37 1 <br /> V" FBI <br /> 1 <br /> 7 <br /> d ,- <br /> _ - i t <br /> QIICUT' .L <br /> Eel <br /> I <br /> ��tc <br /> MENT USVON j V0'4a <br /> Application Accepted v Area -2-1(o _ Employee ID# <br /> Final Inspection By Date 1 ❑ SPEECCIIA77L PERMIT-Approved by / <br /> Character of Soil to Dept of 3 Ft: PiVSump Soll Character: f <br /> COMMENTS L F. es fAi l .w. 0,Ao <br /> PE SC Received �ID <br /> Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service R uest# <br /> 2 t , t a /14 Uy2 <br /> 42-02.001 T ONSITE WASTEWATER PERMIT <br /> 12/221003 <br />