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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JO.AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ave - 3"' FL- S'TUCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIOSS EXPI FS 1 YEA -ROM DATE ISSUED <br />JOB ADDRESS <br />J� �J t, r /fy CITY/Zf/P`� /�q� <br />CROSS STREET ACM01 1'�lJ'— 1 '�+ .�J•" O—) 9 -1 LIL/ .02- <br />APN PAR111. SILL <br />OWNER NAME / Ij (PIIDN'F, <br />OWNER AUURF:Nti 1 i//`1__ ` CITt'(STATE/ZIP ��_ <br />CONTRAC-I'ON ' A - �S S H+/ V � PHONE <br />CONTRACTOR ADDRESSUCb <br />CFIY/STATFJZIY lJ\_ +J 1 <br />LICENSE C-02 ❑ (:-36 OTHER NUMBER_ I N)51 EX PiRAT1UN DAT1^ l 3 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X V <br />J PERC TEST (S) NUMBER LAND USE APPLICATIO9 k <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE: <br />REPLACEMENT _ ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RGSIDENCE COMMERCIAL D OTHER <br />NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />ElIJ <br />SEPTICTANK TYPE/MFG CAPACFFY gal NOFCOMPARTMEN'rS 4� _ <br />U CREASE TRAP TYPE/MFG CAPACITY gal d OF COMPARTMENTS <br />❑ PKC TX PLANT DIST'ANNCETO NEAREST: WF,1.1. 1 ft FOUNDATION 1•i PROPERTY LINE <br />-W It <br />❑ LIFT STATION SIzr 5- TYPE OP PUMP 9AIA ❑ SAND 011, SEPARATOR (ENC -LOSER SYSTEm) <br />LEACH LINES X LEACHING CHAMBERS 12Ptstf .., `0—ofaff)A OF LINES r LENGTH OF LINES too <br />/ y�� <br />DISTANCE it) NEAREST WELL 1l�f _ t1 FOUNDATION �/_fj PROPERTY LINE �} _ j) <br />❑ FILTER BED WIDTR _. ft LENGTH _ ft DEYrH. _ ft <br />DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH fj <br />DISTANCE TO NEAREST WELL _ 1 ft FOUNDATION _t1 PROPERlTYc.L11NE _ . _ _ fl <br />SUMPS WIII'I'H ��C[ LENGTH L_ p ! R DEPTH 1 L-� ft <br />DISTANCE TO NEAREST WELL ft FOUNDATIONR PROPERTY L.INF_ _ R <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH_ -II <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINF. ft <br />❑ SEEPAGE PITS WIDTH _ ft LENGTH - ft DEPTH It <br />DISTANCE, TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ff <br />I HEREBY CERTIFYTHAT I HAVE PREPARED THIS APPLICATION AND "I HE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUI.N COUNTY. <br />11NI 1 11 V NC'E NOTICE REQUIRED FOR INSPECTION'S- PLEASE CALL (209) 953-7697 PAYMENT <br />SICNE- <br />_TLE_� _ DATE RECEIVED <br />'11' - <br />ULYAKIM�E+NII UbLUNL_ 2Y <br />Application e _ ._... DateN7 _ J Area O``I Employee _--V _ <br />_ lDtl' <br />F1nal insction y" LGF <br />Date Cly ❑ SPEC FERMI"1' - Approved by //(('' <br />Chancre oIl to <br />PHI nf3 Fr. ,� Pif/Sumo Snit C'ha rn�lPr . <br />COMMENTS <br />ONSITE WASTEWATER PERMIT <br />