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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUPOY ENVIRONMENTAL HEALTH DEMRTMHIF 304E WEYA AVE-3-PL-SIOCKMN CA 95202 -(209)48-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7197 FOR ISFPECTIOSS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Cm/GP - <br /> CROSS STREET Q _ F�"a-1 J, APN GN 7 - CJ PARCEL rqE,_� a�g <br /> OWNERNAME �Lj--.^... �� 1 CA - _ _ PHONE �j bpi <br /> OWNER ADDRLS `SI W - 1 r'14^ Imo— CITY/STATE21P CJ��pV <br /> CONT R U' PHONE <br /> CONI'MCTOR ASEROS CEEY/STATiILIP <br /> LICENSE 0 C4 0C-36 OTHER NUMBER EXNRATONDATE <br /> WATER TABU Dmr,U 0 GEDUmPHICALINFORMATION: CaoldineteE X V <br /> PERC TEST # FBUILDINGPERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/AWITgN ❑ ENGINEFADESPPIED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: LlRESIDEN[E L3 COMMERCIAL ❑ OTHER <br /> NUMBE0.0F LIVING UNITE: NUMBEROPBEp OUPIE: NUMBERWEMPWYEM: <br /> ❑ SEPTIC TANK TVPF/MFG CAPACITYSol #OFCOMPARTMENTS <br /> ❑ GREASE TRAP T PEJMFG CAAA M gel NOFCOAnARTMENIIS <br /> O PEG TX PLANT DIETANCETONEARPST: WELL At FOUNDATION ft PROPIATY LAI E S <br /> ❑ LIFT STATION Sm— TYPEOFPURIP ❑ SAND OIL SEPARATOR(ENCLOSED SYMEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LMES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION D PROPERTY LINE D <br /> ❑ FILTER BED WIDTR ft IEWOT R DEPT A <br /> DISTANCE TO NEAREST WELL ft wUNDATION A PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH A LENGTH ft DEPTH A <br /> DISTANCETONEAREST WE A FOUNDATION ft PROPERTY LME ft <br /> O SUMPS WIDTH ft LENGTH A DEPTH A <br /> DISTANCETONFARIAT WI it FOUNDATION A PROPERTY LINE A <br /> ❑ DISPOSAL PONDS WgiH ft LENGTH At DEPTH R <br /> DI3'TANCE TO NEAREST WELL ft FOUNDATION H PROPERTY LINE A <br /> ❑ SEEPAGE PITS Nu.." WIDrm ft DEPTH ft <br /> DISTANCE TO NEREST WELL It FOUNDATION E PROPERTVLME ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THISAPPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES.STATE LAWSAND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 21 HOUR.AIIVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEAS.CAI.I.(209)95 3 469 7 <br /> SIGNED TITLE Citi DATE <br /> O N <br /> H T <br /> DEPARTMENT EON _ <br /> AppOotbn AcPled pq Are Empgye lDN <br /> Find lnapeabn DBq�� Vii' moi' ❑ SPECIAL PERMIT-Am ad by <br /> Character a(SoU to Depth a0 PR/Samp Sail Character: <br /> n <br /> COMMENTS —72 <br /> SC ReeMved A.RR, <br /> CRe Real Dabmed llPeaeR <br /> M# IaYNeM PerMltlpl <br /> 222 57,1 3S If <br /> p02JIpI ONSITE WASTEWATER PERMIT <br /> I2 <br />