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ONSITE WASTEWATER TREATMENT SYSTEM MAIN EPERM10 CA9520z-{209)468-sa20 <br /> SAN AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRoM DATE ISSUED <br /> s o 4 CITYIZIP <br /> Jos ADDRESS. � <br /> CROSS STREET L 1/I ` APN "' PARCEL SIZE v <br /> OWNER NAME Q,>� L PHONE <br /> OWNER ADDRESS 1�� CITYISTATEIZIP <br /> CONTRACTOR ���`-2r� LLI'_ PHONE - <br /> CONTRACTOR ADDRESS CITYISTATEIZIP T <br /> LICENSE [SC- 2 [�C-36 OTHER NUMBER &3952i EXPIRATION DATE <br /> WATER TABLE DEPTH. It GEOGRAPHICAL INFORMATION. Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: VCESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: Zk NUMBER OF EMPLOYEES: <br /> W'SEPTIC TANK TYPEIMFG_ L CAPACITY_ �=ZDS gal #OF COMPARTMENTS d� <br /> 0 GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O LIFT STATION SIZE TYPE OF PUMP 13 PKG TX PLANT 13 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> � e 1E W <br /> '01/0LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES ft <br /> TO NEAREST WELL ft FOUNDATION i ft PROPERTY LINE <br /> DISTANCE ft <br /> O FILTER BED WIDTH ft LENGTH ft DEPTH ft "J <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATI N ft PROPER LI ft <br /> 0 SUMPS WIDTH ft LENGT ft DEPTH F ft <br /> DISTANCE TON ST WELL _ft FOUNDATION I ft PROPER LINE ft <br /> O DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAN ES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOURA ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209) 69 <br /> SIGNED AA- TITLE DAT ' <br /> Ij <br /> L c� <br /> AM <br /> r^ <br /> O <br /> EyiOM <br /> ^ x aFll <br /> _ <br /> ITI <br /> DEPARTMENT U -E NLY- <br /> t <br /> Application Accepted By. Date -5 !7 /Q Area Employee ID# <br /> Final Inspection By ate El SPECIAL PERMIT-Approved by <br /> Character of Soil to D th of 3 Pi ump Soil Character: <br /> COMME TS 7-o <br /> PE SC Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 6126109 <br />