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�� J/.�NSITE WASTEWATER TREATMEdSYSTEM PERMIT SCANNED <br /> SAN JOAQUIN COU.�ErvVIRONMENI'AL HEALTH DEPARTMENT WEBER AVE-P°FL-SFOCKTON CA 95203 -(209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL 309 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM <br /> cDATE ISSUED <br /> JoBADDRESS R/ �E'e� C'm/ZIP C n !S a <br /> CROSS STREET pl pY �r?,LD APN �/i-J./ PARCEL SIM. <br /> OWNER NAME ^�N ''J1LyJ�LII.,� �L/pJ�/ PHONE i/V/ �1a/����0/ �y <br /> OWNER ADDRESS 7— Np/L' 6U CITYWATEJZIP s I_./(T/.J C_) <br /> CON1'RACEOR <br /> �— ('� % hoil' PHONE S J <br /> CONTMCEOP ADDRESS N CEFY/STATVZIP C' <br /> LICENSE 13 C42 ❑C-36 OFHER NUMBER EXPIRATION DATE <br /> WATERTABLEDEPTH: B GEOGRAPHICAL INFORMATION: CBOrdinBt. X Y <br /> _ <br /> ❑ PERCTEST B BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSUALLATION ❑ REPAIRIADDITIONL3 ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT —ac//FSTRUC1710N <br /> IMF FINSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> �.LNUMBFROFLIVMG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> �SEPTICTANK TYPE/MFG CAPACITY pi k OF COMPARTMENTS <br /> Q%❑ GREASE TRAP TYPE/MFG CAPACITY Snl 40FCOMPARTMENtS <br /> V <br /> ❑ ?KG TX PLANT DISTANCETO NEARETT: WELL B FOUNDATION R PROPERTY LINE fl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOMI)SYSTEM) <br /> yB ❑ LEACH LINES ❑ LEACHING CHAMBERS NOFLMEs LENGTHOFLINUS ft <br /> DISEANCETONEAREST WELL R FOUNDATION It PROPERTY LINE It <br /> ❑ FILTER BED Wmrx A LENGTH ft DEPTH ft <br /> DISTANCETONEARESE WELL B FOUNDATION It PROPERTY LME ft <br /> ❑ MOUNDED WIDTH fl LENGTH ft DEPTH It <br /> DTSTANCETONEAREST WELL ft FOUNDATION R PROPERTYLME R <br /> ❑ SUMPS WMED ft LENGTH fl DEimU It <br /> DISTANCETONEOEST WELL It FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH B LENGTH B DEPTH fl <br /> DISTANCETONEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WDrcx fl DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> a 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS AP PLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH MN JOAQUIN COUNTY <br /> \�A I NUPS,SEATS Y6 AND RULES <br /> AND REGULATIONS OF SAN]OAQUIN COUNTY. <br /> 1 IMu 92 IOURAD AI NOTICE REQUIRED FOR INSPEC/DNR-PLE CALL 1 9)9)9534697 <br /> SIGNED J TITLE L (J AJ C`�vl DATE <br /> 1�. <br /> F t <br /> IrJ. <br /> }T i_ <br /> TE \ <br /> ~ ' F <br /> U It 11 1 <br /> }* . <br /> U T( <br /> F <br /> tsc N E <br /> 4EWHIrp <br /> �yT <br /> DEPARTMENT UR ONLY <br /> Application Accepted BY to a Arca Employs IDk�•(-'/�j—l(f�t"�— <br /> RNA hrpmtion8 site S ❑ SPECIAL PERMIT-APpmved by <br /> .� ChsimcNr of SBII b,Depth of 3 FC - PIUS imp SIR CbRMCRF: <br /> COMMENTS <br /> IE <br /> PE SC Remived Chec Anmunt Date PM <br /> erU IBvaice0 Permit lDB <br /> Code IF. B Fh Remitted Service R... <br /> Q 75 <br /> Z <br /> BRI, <br /> 42L3-001 ONSITE WASTEWATER PERMIT <br /> 12R]/I00) <br />