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L I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUINCOUNFY ENVIRONMENTAL HEALTH DEPARTMENT 3ME WEBER AVE-3•°PL-SfOCRTON CA 95262-R09)46B-3420 <br /> NON-REFUNDABLE PERMIT I CALL 209 953-7697 FOR INSPECTIONS ''�^E`XPJIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ) I �• lV f (I CITY/ZIP ll kdrile) (1 }�_I-p <br /> L _ )�l <br /> CROSS;BEREFT fLJt1yL 1 1`'C. F-t\ / APN I.L�I 7 C LJ � �P PARCEL SI]Ii jLj_fjL_Ly <br /> OWNER NAME <br /> t�L51!(l JI-L-� 'r �1 PHONE <br /> \ 1 1 <br /> OWNERADDRESR IyJ•-+ (" Y� t� i�VC �Y'�P �' CITV/STATF/ZIP II) HONE <br /> LCONT MORN �A PHONE <br /> CT'/$TATLIZIP <br /> COMACTORADORERS <br /> L I LICCNBE ❑C<2 ❑C-36 O HER NUMBER EXPIATION DATE <br /> WATER TABLE DEPI'N: fl GEOGAPHICALINPORMATION: CDOrdlBelel X Y <br /> FERC TEST # BUILDING PERMIT# LAND USE APPLICATION# )7 <br /> _ TYPEOFWORK: ❑ NEW INWALWTION ❑ RVAIRIADDITION ❑ ENGINEERDPSIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITR: NUMBER OP BEDROOMS: NUMBER OP EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY Bel #OFCOMPARTMENTS <br /> L ❑ GREASE TRAP TYPP/MfO CAPACFFY gel #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONEAREST: WELL ft FOUNDATION S PROPERTY LINE fl <br /> O LIFT STATION SIZE TYPEOFPuMP ❑ SAND OIL SEPARATOR(ENCIOSEOSYSFEM) <br /> L ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCETONAae51' WELL ft FOUNDATION ft PROPERTY LNE ft <br /> ❑ FILTER BED Www_ft IENOTH <br /> It DEPTH ft \ <br /> L DISFANCETONEARIb WELL B FOUNDATION R PROPERTYLNE ft <br /> ❑ MOUNDED WIDTx H LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WmTN ft LENGTH ft DEPTH ft <br /> L DISTANCETONEAREST WEL ft FOUNDATION H PROPERTY LM_ft <br /> O DISPOSAL PONDS WIRTx ft LENGTH ft DEPTH ft <br /> • DISfANCETONEAREFr WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUM6eR WmTx ft DEPTH ft <br /> L DISTANCE TO NARl WELL ft FOUNDATION ft PROPERTY LINEft <br /> 1 HEREBY CERTIFY THAT I RAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE RJ ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES.STATE LAWS AND RULES AND REGULATIONS OF AN JOAQUIN COUNTY: <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE Y E`CALL(209)953-7697 <br /> LSIGNED TITLE /- < , DATE I ' It. • �� <br /> 1�. <br /> J. <br /> d�B.v un w,eT R R .�iawpgr <br /> X16 � <br /> 20 I LOTS 14 - 16 B �� <br /> -I ( il4c&c ,od4B o meg ZC( S. <br /> in I I I I I I I I I I I I I I I I I I I I <br /> UN <br /> Y H q 7 <br /> L <br /> DEPARTMENT YSE ONLY <br /> APPIkaHon Accepted By I�-C 4 Met i t i 1, Am Employee IDN <br /> �I Final Inspection By Det. ❑ SPECIAL PERMIT-Appmvedby <br /> Chaneter of Soll io Deptb of 3 P1: PIUSump Sell Chenetee: <br /> COMMENTS <br /> I <br /> ed SC Received ChgloY/= Amount PerMU <br /> Coda I' B Ce.6 R<mINW Did* fSeMu uMM Invoke# Permit lDk <br /> l i <br /> bee, 4242-001 ONSRE WASTEWATER PERMIT <br /> 12/12!1003 <br />