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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> IN. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 306E WESER AVE 3"FL-SPOCKTON CA 95202 -(209)469-3420 <br /> NON-REFUNDABLEPERMIT /4101 CA LL(2D9 9 3-,7V=IONS EXPIRES YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 J�,p yam' i` 1 LCITr/ZIP Lr-u . C`L,IBIB <br /> CROSS STREET 4-1 A 1- ( k- ` APN U U '� Z l rl- Z T PARCEL SIZE�J CD <br /> OWNER NAME +N1a 1m, 1,G�.^C,�1L1,111_A Or^t �' PHONE y"t-4' ••/d ?-"]-�: 4 <br /> OWNER AD.. 12 _`5 S' 1 Iw .'+L'r.-1 l.e t CITY/STATEIZII Z 3 Z'�1i� T <br /> `., CONTRACTOR Ll O ' PHONE <br /> CONTRACTORADDRESS CITY/STATFJZIP <br /> LICENSE ❑C-02 0C-36 OTHER NUMBER EXPIRATION DATE <br /> 6. WATERTABLEDEPTH: ft GEOGRAPHICALINFORMATION: C000HIYtel A Y <br /> PERCTEST # -Z..- BUILDINGPERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW I NSTALLATION ❑ REFAIR/ADOITION ❑ ENGINEERDMiGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> LI INSTALLATION WILL SERVE: ❑ RESmENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPC/MFG CAPACITY gal #OF COMPARTMENTS <br /> L ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DIWANCETO NEAREST: WELL ft FOUNDATION R PROPERTY LINE R <br /> L ❑ LIFT STATION Sin TYPE OF Pump ❑ SAND OIL SEPARATOR(ENCLOSE)SYSTEM) - <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH DF LINES R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTU, R <br /> 1 DISTANCETONEAREST WELL R FOUNDATION R PROPERTY LINE R I <br /> L ❑ MOUNDED WmTX ft LENGTH It DEPTH It <br /> DISTANCETONEAREST WELL R FOUNDATION a PROPERTY LINE R Z <br /> ❑ SUMPS WIDIN ft LENGTH R DEPTH ft <br /> DISANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> _\ <br /> L ❑ DISPOSAL PONDS WIDTM ft LENGTH It DEPTH It <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE R `{ <br /> ❑ SEEPAGE PITS NuMReR WIDTH ft DEPTH ft <br /> DISTANCETONEARESr WELL It FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY I' <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M INI M UM 14 HOUR A DVANCE NOTICE <br /> `REEQU[RFD FOR INSPECTIONS-PLC4SE CALL 12M)953-7697 <br /> [ SIGNED -+ _ , 2 F---�TITLE C--- S__ 4— 4� I DATE it J c, Is, - <br /> I <br /> pv <br /> L <br /> -aVIhol IMIN <br /> T <br /> 1 ' <br /> V <br /> /! DEPARTMENT�SE/pPLY <br /> Applfomion A¢epted By <- Clv.-�-�-- D.fe Area EmpiDya Off <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> ` Ch.mctar.T Soil fa Deylh a0 FD PWSamp Sall Character: <br /> COMMENTS <br /> LPE SC Raelved CCpepidf{ Amount �� Permi4 Inmitt# Permit lD# <br /> Cade INTO B Cash ReMtled SIM'. aeMp <br /> _ A CJI L ,� <br /> 42-014101 ONSTIE WASTEWATER PERMIT <br /> ' I2RXJI03 MI. r Ix r ,i_ , ._ <br />