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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN <br /> JOAQlIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3D4 E WEBER AVE-3YO FL-STOCXTON CA 95202-(209)46"20 <br /> SAN AN=FUNDABLE PERMIT CALL 249 9,53-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> CrrY21P <br /> CROSS STRE¢T _y,/Y K! rrl- ilk ,G�— APN 2.:J 2• PARCEL SIZE, 9 <br /> _ '• _ �� ^_' PHONE <br /> I OWNER\AME !.,!a <br /> + OWNERAODRKS F7i/IT CITYISTATFJZJP <br /> PHONE <br /> CONTRACTOR 1=4 <br /> CITYfST <br /> CONTRACTOR ADDRSSS <br /> LICENSE C42 0 C-36 OTHER NLMRER E%PIRAIION DATE f <br /> WATER TABLE DEPTH: <br /> ft GEOGRAPHICAL INFORMATION: COOrdMRlea X Y <br /> ❑ PERC TEST # BUILDING PERMIT#_- _LAND USE APPLICATION#. <br /> TYPE OF WORK: O NEWINbTALLA7I- REPAIR/ADDITION ❑ E.NCINEERDESIGNEDIALTERNATIVE <br /> O REPLACEMENT. CI DESTRUCTION <br /> INSTALLATION WILL SERVE: IDenCE ❑ COMMERCIAL <br /> ❑ OTHER_ <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS' NUMBEFiOP EMPLOYEES: <br /> ❑ SEPTIC TANK TYPElMFG _ CAPACITY,1�0 LJ pl S OF COMPARTMENTS <br /> ' CAPACITY gal #OF COMPARTMENTS ^n <br /> ❑ GREASE TRAP TYFFJMFO K3 <br /> ❑ PKC TX PLAIT DISTANCE TO NEAREST: WELL_ R FOUNDATION fnR PROPERTY LINE 2• <br /> ft <br /> ❑ LEFT STATION Sl7.E TvPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> tM.} <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS „LF-'4-W.Gu#OF LINES LENGTH OF LINES %✓d�- ft "V <br /> DISTANCE TONEARFM WELL 6M_ft FOUNDATION_---Lo—R PROPERTYLLNE �� R <br /> ❑ FILTER BED WIDTN _ <br /> R LENGTH ft DEPTH it <br /> ft <br /> DU-TANCE TO NEAREST WELL _ _ R FOUNDATION__.�_.__R PROPERTY LINE. <br /> C) MOUNDED WIDTH__ft LFVGTH _ R DEPTH -ft <br /> DISTANCETONEAREST WELL_ R FOUNDATION- ft PROPERTY LINE_ ft <br /> ❑ SUMPS WIDTH ft LENGTH ft <br /> DEPTH It <br /> DISTANCETO NEAREST WELL _R FOUNDATION ft PROPERTY LINE__ R <br /> ❑ DISPOSAL.PONDS WmTx _R LENGTH_ ft DEPTH ft <br /> DISTANCE TO NEAREST `WELL _ R FOUNDATION _ R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION__ R PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I AVE PREPARED <br /> R <br /> ORDINANCES. THIS <br /> APPLICATION AND ANDES THE <br /> REGULATIONS WILL <br /> E DO.-4E IN.IOA ACCORDANCE <br /> WITH SAN JOAQUIN COUNTY <br /> MINIML1 4 HOU DVANCE NOTICE.REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED TITLE DATE -V <br /> G <br /> \ N UN N <br /> E <br /> DEPARTMENT US ONLY L/t� �./ <br /> Date <br /> P. L Area, Employee[DF LY_5 '7f <br /> Application Aceeptrd y J <br /> Final Ins Date._ d.. �__. Datc' ❑ SPECIAL PERMIT-ApProvedby_ <br /> Character of SM to th o Ft; Pi1lSump Sail Character: <br /> COMMENTS r -nom 'e <br /> PE SC Received Cheek#/ Amount DateInvoice# Permit ID# <br /> Code INFO B Remitted <br /> ervice R uecT+Y <br /> r <br /> ONSITE WASTEWATER PERMIT <br /> 47-02-001 —� <br /> 1:.2Z+1003 <br />