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ONSITE WASTEWATER TREATMENT SYSTEM AIN PERMIDN CA 96202-(209)4663620 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR DATE ISSUED <br /> � <br /> JOB ADDRESS ; �i 14 5115 Lo ISD• CIIYZP S�Lr—� � 'J �/ > <br /> n10(Z11.1AI KVt . APN (D3'z90-3o PARCELSIE `•I•r`� bBx <br /> CROSS STREET '3. (J,�f G <br /> • OWNERNAME WILLtA�v �A/�ZD1 �L/ /�f�1y. ` PHONE <br /> -{� 1a,�,p• `�r� !- <br /> Z 1 i /J• I V M`7 CT'/STATEIZIP 5nc w-•'" c • Q i L1 J <br /> OWNER ADDRESS ��//G S _ �/ <br /> CONTRACTOR wlife OKK EAA.I�1'�1/IVmE/V InL PHONE 3�q�03 QyS?�h(•O <br /> CONTRACTORADDRESS 4o-4 �- Ohl- ST' CLTWSTATEZ L•ODI � % T <br /> LICENSE QC-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: <br /> ft GEOGRAPHICALINFORMATIGN: COOrdinate6 X Y <br /> - <br /> 'I� PERCTEST # 2 BUILDINGPERMIT# LAND USE APPLICATION# <br /> ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> TYPE Of WORK: ❑ NEW ACEM LATON ❑ REPAIRIADDITO0 DESTRUCTION <br /> ❑ REPLACEMENT <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> CAPACITY 981 #OFCOMPARTMENTS <br /> ❑ TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GGREASREASE TRAP TYPERdFc It <br /> DISTANCE TO NEAREST: WELL R FOUNDATION <br /> It PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ft <br /> Ll LEACH LINES ❑ LEACHING CHAMBERS #OF LINES ft ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION—R PROPERTY LINE <br /> It <br /> [3 FILTER BED WIDTH k ft DEPTH LENGTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> f: <br /> DEPTH ft <br /> O MOUNDED WIDTH k LENGTHk PROPERTY ONE n <br /> DISTANCE TO NEAREST WELL k FOUNDATION it <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH <br /> ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br /> C1 DISPOSAL PONDS WIDTH ft LENGTH k DEPTH <br /> DISTANCE TO NEAREST PROPERTY LINE ft <br /> E6T WELL k FOUNDATION It <br /> • ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH <br /> DISTANCE TO NEAREST WELLR FOUNDATION <br /> k PROPERTYLINE it <br /> I HEREBY CERTIFY THAT I HAVE PREPARESTATE <br /> ATTE LAWS AND ON MRULEAND REGULATIONS SAN D N ACCON COU ANCE WLTH SAN JOAQUIN COUNTY ORDINANCES, <br /> MINI HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASECALL(209)963-766997 <br /> SIGNED TITLE LCAttu WERI"r <br /> DATE <br /> M07' <br /> Petr un 2 <br /> l <br /> p ' L <br /> (OJW <br /> y <br /> _ C3 cyco <br /> ¢f <br /> a <br /> Z UW <br /> m <br /> ° DEPARTNI 5 O LY (� <br /> Application Accepted By <br /> Date Area EmPloyea ID# <br /> FInaraero IonSoil <br /> By <br /> Data ❑ SPE IAL P RMIT-ApProvetl by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> • COMMENTS <br /> PE SC Received hoc Pmount Date PermlU Invoice# Permit lD# <br /> Coda INFO B e6 =led Se ica Re St# <br /> 14x1 <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />