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ONSITE WAEWATER TREATMENT SYCM PERMIT <br /> SAN 30AQUIN COUNTY ENVIRONMENTAL HEALTphe:PARTMENT 304 E WEBE.`_JE -3""FL-STOCKTGN CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT/ CALLS(2099))953-7697 FOR INSPECTIONS EXPIRES IY.-EAR F OM DATE ISSUED <br /> 30B ADDRESS CITYIZIP /�����/C. �c m <br /> CROSS STREET �`'��✓� APN 17 ISD r 3(JPARCEL SIZE <br /> 'y / �v <br /> OWNER NAME / C ;/� PHONE(-()9)/�~�/(�>�L! Mn <br /> OWNER ADDRESS /] _���//// /� L��rCITYISTATEIZIP e� <br /> CONTRACTOR / '� C- - PHONE �L'f <br /> f/ ` �� CITY/STATEIZIP <br /> CONTRACTOR ADDRESS )' / / LyC� /� /pZ�_ J� <br /> LICENSE C3 C42 QC-36 - OTHER C-?--I Alf Z-NUMBER �^' � EXPIRATION DATE...-.....,::2 <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> i <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAtRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION ! <br /> t <br /> tNUM <br /> TION WILL SERVE: RESIDENCE © COMMERCIAL ElOTHER <br /> BER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS i <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft C.- <br /> C3 <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft V <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft G <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 11 C�' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl . <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEP'T'H ft Z <br /> � I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I <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 JOAQ'UIN COUNTY. _ <br /> MI U ICE REQUIRED FOR INSPECTIONS-PL 5 L(2 )953-7697 Q <br /> SIGNED TITLE �J�f�T�.�./ DATE <br /> T <br /> n <br /> R <br /> 0 -1 <br /> S Is ' <br /> - i <br /> DEPARTMEN US ONLY �f <br /> Application Accepted B Date Z- Q Area 21 i Employee ID# <br /> Final Inspection By Date VA, ElSPECIAL PERMIT-Approved by <br /> Character of Soil to D th of 3 Ft: Pitisump S it Character: ++ <br /> COMMENTS '.r.�;�l -a`�^� s4rr„ �c S2 ' -, d t o <br /> I <br /> i <br /> PE SC Received Check#I Amount Date Permit) Invoice# Permit ID# 1 <br /> Code INFO By Cash Remitted Service Request# <br /> 22 971 D 81_ -?(9104 Roo 3 sfS <br /> 42-01-001 <br /> 1212!02 ONSITE WASTEWATER PERMIT <br />