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�' 03e�!!�a <br /> ONSITE WASTEWATER TREATMENT SYSTEM EI2NII <br /> SAN JOAQUIN CO NVIRONMENTAL HEALTH DEPARTMENT JEWESER AVE-3-FL-STOCRTON CA 95202 -(209)168.3420 <br /> NON-REPDND�PERMIT CALL(209)953-7697 FOR INS /PIONS EXPIRES 1 TR FROM DATE ISSUED <br /> v <br /> JOBADORESSL CR/Y/ZIP <br /> CROSSSTREET /L.r� /�(� APN If)) nT PARCELSIZE92') a <br /> Bass OWNER NAME D,020 PHONE G <br /> OWNER ADDRESS Mp c /^/ ^J� CITY/STATTJLIP <br /> CONTRACTOR '44�e'-1 S,Lei .f/ �FIU c- PHONEBase <br /> CONTRACTOR ADDRESS�C�. L7 -7I( C�IT�Y//STATE21P <br /> LICENSE -42 0C-36 OTHER NUMBER TY7 Z EXPIRATION DATE-J Q <br /> WATER TABLE DEPTH: / ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ban ❑ PERCTEST(S) NUMBER LAND USE APPLICATION <br /> TYPE OF WORK: -X NEWINSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER t <br /> NUMBER..LIVING UNYIS: �I� ) NUMBER OF BE.DyRROOOM& NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG�vJLV �)11JG'C/ CAPACITY Rel NOFCOMPARTMENTS mC 1 <br /> ❑ GREASE TRAP TYPFJMFO tf CAPACITY �'�a-''� Bel NOFCOMPARTMENTS <br /> ` ❑ PKGTXPLANT DISTANCETONEARE6T: WELL YO ft FOUNDATWN� R PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENcLoszv SVsfEM) <br /> L LEACH LINES ❑ LEACHING CHAMBERS JL5-' NOFLINES JE LENGTH OF LINES t40ft <br /> DIWANCBTONEAREST WELL leOp�-R FOUNDATION 4OV) R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> L <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ` <br /> 114 ❑ MOUNDED WIDTH ft LENOTN ft DEPTH ft <br /> DISTANCETONEAR.ST WELL ft FOUNDATION ft PROPERTY LINE ft 1 <br /> ❑ SUMPS WIDTH 0 IEN&H ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH It <br /> DISGNCETONEAREST WELL ft FOOUUUNDAMN ft PROPERTY LINE R <br /> Ix SEEPAGE PITS WIDTH R L 'J R DEPTH �$— I ft <br /> ETT <br /> DISTANCETONEARWELL FOUNDATION 4 T( it PROPERTY LINE %39147__e <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN IM UM U HO UR ADV AN ENOTICE REQUIRED FOR INSPEE IONS-PLEASE CALL(2W)953-7697 rT <br /> SIGNED N7d?!✓�TpJ�'PIYTLE /'d''D � DATE <br /> IF <br /> P00 UC LIHSEP ICC <br /> L <br /> LF DEPART USE ONLY ��/'� / '^ <br /> Application AccePtetl -� ate A. EmploYtt I041 -31r-•� <br /> Final Inspection Date 7 ❑ $PECI PERMIT-Approved by <br /> u' Charasterof Soil to D,H6 of Ft. PIUSump Soll Character: e��p�irl9.alb <br /> ` COMMENTS P — 30 ,�, �Gi5..3' <br /> PE SC Received ec Amount Permittl <br /> Code Inro .B ash Remitted Date Service R ueMN Invaicep Permit lDp <br /> /v R00 <br /> 12-01.001 - ONSITE WASTEWATER PERMIT <br /> 11n1112 <br />