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ONSITE WASTEWATER TREATMENT SYSTEM TPERMIREET- T <br /> NfA95zoz (209)468-3420 <br /> SAN JOAQUIN COUNTY ENVIRON>IFNTAL HEALTH DEPARTMENT 600 E <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> �9SL _ <br /> JOB ADDRESS LI/7 _ C(I'T�Y'I7.IP /nhi -1 <br /> CROSSSTREET At5r .- - APN <br /> ` PARCELSIZF� p <br /> A <br /> OWNER NAME C 75-17+141.6-1 PHONE q- 27 <br /> OWNER ADDRESS q'Y7A 1�AA./5cci AA12S CITY/STATE/ZIP Iifh i' ('A 95z& <br /> CONTRACTOR _ PHONE <br /> CONTRACTOR ADDRESS c CITY/STATE/7.iP `p <br /> LICENSE 0 C-42 0 C-36 NUMpER E%PIRATION DATE <br /> \pp <br /> WATER TABLED � PG MY.qNFOR.UTTON: Coordinates x \' <br /> 0 PERC TEST # ;SIF LAND USE APPLICATION# <br /> TYPE OF WORK: N' L� e�W Cl REPAIR/ADDITION ENGINEERDESIGNED/ALTERNATTYE <br /> �b1E N 0 DEsTRUCITDN <br /> INSTALLATION WILI ht�\R\IIYEE`,V�� RESIDENCE O COMMERCIAL O OTHER <br /> NUMBER OF LIYTNG 1a'1TS: NUNIBER OF BEDROOMS: NITMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPEIMFG­jrZL CAPACRY gal #OF COMPARTNF.\TS <br /> O GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O LIFT STATION SIZE TYPE OF PUMP O PRG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES Ll LEACHING CHAMBERS #OF LINES�_ LENGTH OF LLNFS V n <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE n <br /> (3 FILTER BED WIDTH n LENGTH ft DEPTH n <br /> DISTANCE TO NEAREST WELL n FOUNDATION It PROPS ft <br /> O MOUNDED WmTe n LENGTH n n <br /> DISTANCE TO NEAREST WELL n FOUNDATIONR % LNE n <br /> 1 I <br /> 10, SUMPS WIDTH __n LENGTH EPTH 1 I) <br /> DISTANCE TO NEAREST WELLn•--{)G) . `e6 &R`1 Y _n <br /> 0 DISPOSAL PONDS WIDTH ft LENGTH _ 'f)e�Q� EPT.IA e'f -- — n <br /> DISTANCE TO NEAREST WELL fl FOUtiDATLNc a `�'U\P, T n <br /> O SEEPAGE PITS NUMBER WIDTH P.,�I Cid ``'' 7�Sih n <br /> DISTANCE TO NEAREST WELL. ft FOW!0 ,jV" �1. [t PROPERTY LINE fl <br /> i <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE hORYg` rL!'B$DONE IN ACCORDANCE WITH SM'JOAQUIN COUNTY <br /> ORDIN4NCFS,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> IN MC NI 24 HOUR ADVAN('E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95--t-7697 <br /> SIGNS TITLE DATE <br /> I <br /> Ir I <br /> r I <br /> -1p 84u <br /> I � <br /> A fi/ <br /> ' r <br /> I p <br /> M <br /> EPARTMENT SE ON <br /> Application Accept Date Area Employee ID# <br /> Final Inspection By Date 13 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Ow 11(9 (IFFy <br /> 7-7 <br /> PE SC Received Amount Date Permit/ Invoice# Permit IDN <br /> Code INFO Cash Remitted Service Reque,t a <br /> 42-01 ONSITE WASTEWATER PERMIT <br /> 051GQao7 <br />