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L <br /> L ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQIIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3W WEBER AVE-30°FL-STOCNTON CA 95202-(20)e6$-3420 <br /> NON-REFUNDABLE PERMIT 1C1-ANLL J209953-769\'77 FOR INSPECTIONS EXPIRES I YEAR mom DATE <br /> I-SSSUU.ED <br /> L JOBADDRESs I -0 S CIX 11hj�'�'---•' (--�'6n ✓ <br /> CROSS STREETC,A^ro APN 2Z ��I]r J- 15 <br /> } PARCEL SI2L ^� y{ <br /> OWNER NAME 1 J <br /> L OWNER ADDRESS -+ -•� -` -' (S CTFYISEATFILIP �S <br /> CONTRACTOR `� PHONE -1 ' <br /> COMGCFOR ADOIIE% CEEYISTATF/21P <br /> L IO <br /> LICENSE ❑C42 ❑C-36 UMBER NUMBER EXPIRATION <br /> N DATE <br /> WATERTABLE DEPI'N: ft GEOGRaPHICALINFORMATION: Co010Ftn X Y <br /> FERC TEST If BUILDING PERMIT# LAND USE APPLICATION# � <br /> TYPE OF WORK: ❑ NLW INBEALIATION ❑ REPAIR/ADp1T10N O ENGINEERDFSIGNEDIALTERNATIV .fft <br /> L LIREPLACEMENT ❑ DMURUCEION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE LI COMMERCIAL ❑ OTHEn <br /> NUMBER OP LIVING UHRS: NUMBER OF BEDROOMS: NDMBBROFEMPLOV[ES: <br /> ❑ SEPTICTANK TYPE/MCAPACRY gel #OFCOMPARTMENTS <br /> L ❑ GREASETRAP TNTEJMFO CAPACOY SilNOFCOMPAR MEN S <br /> ❑ PKG TX PLANT DISTANCETONEAReBT: WELL R FOUNDATION A PROPERTY LINE fl <br /> ❑ LIFT STATION SIEE TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED EVEMM) <br /> L13 LEACH LINES LILEACHING CHAMBERS #DFLINES LENOTHOFLINEE ft <br /> DIETANCETONEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTR R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> L ❑ MOUNDED Wroterft LENDTX ft DEPTH ft <br /> DISTANCETONEAREST WELL R FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH A LENGTH R DEPTH ft <br /> DISTANCETO NEAPE4T WELL fl FOUNDATION ft PROPERTYLINE ft <br /> L ❑ DISPOSAL PONDS WIDTH_ft LENGTH ft DEETN ft <br /> DIETANCETONEARFST WELL ft F0UNDATNIH R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NULn. Wnrx M1 DEPTX ft <br /> DISTANCETONEARM WELL ft FOUNDATION R PROPERTY LINE ft <br /> L I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF BAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 12091 953-1697 <br /> SIGNBQ TITLE DATE K/'��• 'C�O <br /> L N — <br /> 1 <br /> 1 . <br /> LIL , <br /> L . . <br /> r / DEPARTMENT PSEp/NLY <br /> Application Acc,,NMI By Data 2 IBI Arca Employs lD# �r i <br /> Final Inspection By Ease ❑ SPECIAL PERMIT-Appnve'1 by <br /> Chanctec of Soil to Depth of 3 FD PIUSBmp Soil CluneteT: <br /> COMMENTS <br /> LPF SC Randie6 Chs AmBYnt Date Perm1U Invelaell Pests,IDB <br /> C96e INxO B iih ReMRN 'TYRE BEM# <br /> L y1.2T j1r ^I 1 M( et) ' NI ) L4 <br /> 01-02-001 ONSRE WASTEWATER PERMIT <br />