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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HE1I,LTH DEPARTMENT 600E MAIN STREET-$TDCKTON CA 95202-[209)468'3420 <br /> NON-REFUNDABLE PERMIT CALL 208 953-7697 FOR INSPECTIONS' EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jae ADOREss q2.1'3 CITYIZIP <br /> -1 4?t;JLL�?� APN OO-A- 310-IO PARCEL SREI�'M ,AC b <br /> CROSS STREET <br /> - "OWNER NAME' �Of t`rl X(�1� PHONE <br /> OWNER ADDRESS [J[D y.� E )�h Y-.1�J Lf-J. CrrYISTATEIZIP <br /> CONTRACTOR LIVE C>A14 ISL Ugh) �Y+�i�J.•L hJ"t¢L- PHONE la"Dry/ <br /> CONTRACTOR ADDRESS q0-1 QAV_ 5T, CITYISTATERIP. <br /> -LICENSE QC-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: A GEOGRAPHICAL INFORMATION: Coordinates X Y � <br /> -W FERC TEST 0 7. BUILDING PERMIT# LAND USE APPLICATION# PA-f oaf'4.! r <br /> TYPE OF WORK: 0 NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED IALTERNATIVE <br /> .. O REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ElCOMMERCIAL OTHER <br /> NUMBER OF LNING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> -0 SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> .0 GREASE TRAP TYPE/MFG _ __ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE 70INEAREST: WELL ft FOUNDATION ft PROPERTY LINE it <br /> 13 LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 13 LEACH LINES ❑ LEACHING CHAMBERS #OF LINE5 LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL - ft FOUNDATION ft PROPERTY UNE ._._._. <br /> O FILTERSED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> (3 MOUNDED A WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> n 1 SUMP$ WIDTH 'ft LENGTH ft DEPTH . • ft <br /> .r. <br /> DISTANCE TO NEAREST WELL it FOUNDATION N PROPERTY LINE ft <br /> U DISPOSAL PONDS WIDTH- ft LENGTH ft DEPTH ft <br /> �- DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE It f <br /> C3 SEEPAGE PITS NUMBER WIDTH It DEPTH ft i <br /> In DISTANCE TS NEAREST WELL ft 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 ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS•PLEASE CALL(209)953.7697 <br /> SIGNED ��"'C TITLE S� T&'�� .__ DATE <br /> I 7_10 <br /> rl It <br /> E <br /> € LC <br /> 1 I a <br /> i <br /> p Ii I <br /> EE 4VI Io M <br /> I <br /> ,I <br /> s <br /> �r DEPARTMENT VSE OMLY <br /> Application Accepted By, fes_ Date Area Employee ID# 57! ( <br /> Final Inspection By -- Date [I SPECIAL PERMIT-Approved by-./J`/ <br /> Character of Sall to Depth of 3 F: Pit/Sump Sall Character: <br /> COMMENTS <br /> PE SC Received Checld!! Amount Date Permit! Invoice# permit ID# <br /> Code INFO By Cash Remitted Service R uest# <br /> ! <br /> 112-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />