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D&"" ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER A VF.-3`FL-STUCKTON CA 95202-(209)468.3420 <br /> NON-REFuNDAB�LIF.PERMIT <br /> , �G n CALL(209)953-7697 FOR INSPECTIONS TEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 41Q,3CJ ,-7, CvR�c.1�cL _HOI.LAW F-V. CI7't'1'ZIP ._ <br /> n - 'n <br /> CROSS STREET GLOV _ APN �2(,>'?9/ n _ r <br /> per+ P', <br /> �) /P�AIR�CpP.I.SIZE1 by <br /> OWNER NAME �Fr.J- [S K1"�'LTL.�.pL,QK. �tPPHHONF. Y{�� / y VQ <br /> OWNERADORESS V. UPr J��L► CITY/STATEIZH' w J'� CLi�T_£I'` 61 (/{7— <br /> CONTRACTOR <br /> CONTRACTOR 5 VMrQ;'C- A� <br /> CON`rRACTORADDRTSS 4S5 I..1• k,J F-ai�Qy,]{{� TX��^.� CITY/STATEIZIP <br /> LICENSE hFc-42 ❑C-36 OTIIER NUMBER 75,9598 EXPIRATION DATE. O 7 V <br /> WATER TABLE DEPTII: ft GEOGRAPHICAL INFORMATION: Coordinates X Y N <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION p REPAIR/ADDITION U ENGINEER DESIGNED IALTERNATIVE IVO <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 151-RESIDENCE ❑ COMMERCIAL ❑ OTHER___ <br /> NUMBER OF LIVING UNITS:_ ( NUMBER OF BEDROOMS: _ NUMBEROF'EMPLOYEES: <br /> ❑ SEPTIC TANK TYPFIMF'G_— CAPACITY gal 0 OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFC;------ CAPACITY_. gal #OFCOMPARTMEN'FS / q <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL fl FOUNDATION R PROPERTY LINE ft v! <br /> 0 LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> e <br /> ❑ LEACH LINES 0 LEACHING CHAMBERS ` �Z #OF LINES L _ LENGTH OF LIVES <br /> DISTANCETONEAREST WELL N.�A _ft FOUNDATION IOt 11 PROPERTY I.INF, <br /> ❑ FILTER BED WIDTH ft LENGTH .ft DEPTH___ <br /> DISTANCE.TO NEAREST WELL__ _ ft FOUNDATION. ly PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH — ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH -_ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL -ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTR _ _ ft LFxGTH_ _ ft DEPTH <br /> DISTANCE TO NEAREST WELL R FOUNDAT.ON ft PROPERTY LINE ft <br /> ..__. <br /> ❑ SEEPAGE PITS WurrH R LENGTH _._ ft DEPTH ty <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERLY LI NE fy <br /> I HEREBY CERTIFY THAT1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> -%TATE t.A W S AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI M 21 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI <br /> ON <br /> S-PLEASE+C'tA�L.IL((2209)953.7697 <br /> SIGNED _ TITLE__�{V {�'C v1yY�•� DATE UJIC�J 1�� <br /> I <br /> 7- <br /> Z <br /> N D E <br /> -M2! <br /> -WEPARTMENT SEOv Y' <br /> Application Accepted&th <br /> Date_ N,1 7 Arca ///A lmployee LD#_,��� <br /> Final Inspection By _ Date Zr 'T— ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to of 3 Ft: __ PiUSump it Charv'f r� _ <br /> COMMENTSl�,Ir�''UZ..-fir <br /> PE SC Received 'hec Amount Date voice# PermltlD# <br /> Code INFOv sh Remitted Service Request# <br /> 1515") It IR D a IAC?' <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />