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ONSITE WAS' EWATER TREATMENT SYSTT V209E)YU44 <br /> SAN JOAQUIN COUNTI'EN\'IRONM1IENTAL HEALTt. 'A RTMENT 304EAVEBEI '.�� 2O <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONN ~ '*EXPIR R' 99E.D� <br /> JOB ADDRESS Lr CITY/ZIP - �L <br /> /!� r� +;j Yl' <br /> CROSS S'I'REtI'I' �7��5 APN / �' /`'I V� y`✓_'�P RCCELSI2E F Q <br /> OWNERNAME U�TN SOy`^/ Ij� I /C� PHONEX�/ '�'93�/16z/nil � <br /> OWNER ADDRESS (� [ X10/` c CITY/STATEIZIP <br /> CONTRACTOR �` // PHHONNEE 3 2- <br /> //��1� lq <br /> CONTRACTOR ADDRESS C r `�C/ �G ) / t CITY/STATEIZIP LC/O� cxO((�� <br /> LICENSE El C42 ❑C-36 OTHER NUMBER EXPIRATION DATE Q0 <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: CBordlnatrS X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION N <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: NUMBEROF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gel N OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal N OF COMPARTMENTS <br /> ❑ PKG TX PLANT' DISI'ANCE'1'O NEAREST: WELL II I.00NDA'HON R PROPERTY,LINE <br /> ❑ LIFTSTATION SIZE TYPE OF Pu51P ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 1 ' <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS NOF LINES LENGTH OF LINES Il <br /> DISTANCE TO NEAREST WELL Il FOUNDATION R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL Il FOUNDATION H PROPERTYLINE Il V 1 <br /> ❑ MOUNDED WIDTH H LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL It FOUNDATION H PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH R <br /> DISTANCETO NEAREST WELL H FOUNDATION H PROPERTY LINER <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH R <br /> DISTANCETO NEAREST WELL n FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL 11 FOUNDAI ION n PROPERTY LINE n <br /> I HEREBY CERTIFY THAT I HAVE.PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE ,AWS AND RULF,S AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 24 U DV CE NOTICE REQUIRED FOR INSPE 'ONS-P SE CAL 953-7697 qp <br /> SIGNED — TITLE DATV / v <br /> O <br /> M T <br /> H <br /> j <br /> f <br /> QT <br /> �R <br /> DEPA T RTMENtINE 1]1-\' �' <br /> Appllollon Accepted Hy DRIB Ara <br /> Final Inrpectlun By Date ❑ SPECIAL1. <br /> i li I �y Y is <br /> Charecicr of Soli to D p1 of 3 Ft: PIVSump Soll Chancier. ai <br /> COMMENTS ( S ✓Itis 6 �eL <br /> iib ! T'w—z- e)711= <br /> PE SI y Recehed C'hmkA' AI Pmnk/ "4{a Perm111DM <br /> Dale <br /> Code ISI N. aRrmBlyd Sen itt R ual■ <br /> S' 67r gif f Ie fv S( 5LOo 5aP' F <br /> i7 •o��[:'J - iso/ ,.rr.,���-1gcHi.ytyc'S.'.s�R�3 t/!�U%�r7J ER <br /> Ilrl b7 /.b�i�-rGyl�f14 •S•7 4&r 7�'�i�Apte' -�/�j ✓.�7La.�3�. : ' Irl TEM•ATER PERMIT y . <br />