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/6 .? 65' 9Pit- 0 3 6+ ' �s <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />NAN JOAQUIN COUNTY ENYIRONMEN JAL HEALTH DEPARTMENT 304 E WEBER AN'F. - 3—FL- ST'O(.TCTON CA 9520: - (209) 468.74241 <br />NON-REFINDASLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRONT DATE ISSUED <br />Jon ADDRESS �i )y BGG tL.. q CITYt1ZIP��CJ 171'L—�.>� <br />CROSS STREET i�``�" i �i ._...._ 'VPN { a�.y — U( PARC Ft. SIZE <br />OWNER NAME _ _ �4�d Y 1 { I � __ ._ PHONE TTT������"- <br />OWNER ADDRE::C <br />CITYISTATE)ZIP <br />CHRTRACTtIA�., lr..�S �(C{{, Ius>✓. 7'i 1'✓r e C— _ --. PFIO'1E 141 s ;(V -,a �* sc— <br />l t <br />I, CONTRACTOR ADDRESN pp &.?%[ GZS(� C17Y'ISTATF.i LIP <br />r <br />p <br />LICENSF. ❑ ('-42 ❑ C-36 ()THFR I Ec <br />P� <br />_ NLS18ER l.fl u3 `.fes !I <br />FAPIRATION DATE_ d 001 <br />_. CAPACIIY D_ gal 10f COMPARFMEN"CS,� <br />� <br />WATER TABLE DEPTH: II <br />GEOGRAPHICAL INFORMATION: Coordinates k <br />Y <br />LlPKG TX PLANT <br />DISTANCE ro MAKES['! <br />❑ PER(' TEST (S) NUMRFR <br />LAND LISE APPI. ICATinN N <br />❑ LIFT STATION <br />SIZE <br />._ r <br />TN PE OF WORK: NEW INSTALLATION <br />LI REPAIR/ADDITION <br />❑ ENGINEER Di.SIGNED !ALTERNATIVE <br />1 <br />u 01 LmEs LENGTH OF LINES 4, OI it <br />_ 1v <br />❑ RECLACEMENT <br />Cl DESTRUCTION <br />_-_-� <br />❑ FILTER RED <br />WIDTH <br />INSTALLATION ' WILLSERVE: �t:SIDENCE <br />❑ COMMERCIAL <br />-- <br />❑ OTHER_ <br />DISTANCE TO NF.AREsi <br />r ^ <br />v <br />NvYiBEROFLIVINc Ulmn'S: 1 <br />NUMBER OFBIEDROOMS' 3 <br />NUMBEROP EMPLOYEES: <br />d LENGTH <br />l <br />U SEPTIC TANK <br />TYPbiMFG_ Y <br />_. CAPACIIY D_ gal 10f COMPARFMEN"CS,� <br />❑ GREASE TRAP <br />TYPr,;ll T_ <br />CAPACITY g3l N OF COMPARTMENTS <br />LlPKG TX PLANT <br />DISTANCE ro MAKES['! <br />1 <br />WELL �O <br />_ <br />1p <br />R F'OU'NDATION I: PKOPEx'rY LINE SIJ+ A <br />❑ LIFT STATION <br />SIZE <br />TYPE OF PUMP <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />41, LEACH LINES <br />❑ LEACHING C'.HAMRERS <br />1 <br />u 01 LmEs LENGTH OF LINES 4, OI it <br />DISTANCE TO NEARF.NT <br />1 <br />WELL �� <br />ft FOUNDATION 1yti PROPERTY I.INF. u () _ It <br />❑ FILTER RED <br />WIDTH <br />R Lt NG'IH <br />_ it of PTH _ _ _ R <br />DISTANCE TO NF.AREsi <br />WELL _ <br />P FOUNDATION ft PROPERTY LINE It <br />❑ M(ICNDED <br />WIDTH <br />d LENGTH <br />ft UFPTH Il <br />DISTANCE TO NEAREST <br />WELL <br />It POCNnAT10N II PROPERTY l.lyE ft <br />ti11MPS <br />WIDTH a.. <br />ft LENGTH _ is I <br />_ 0 DT PTH <br />DISTANCE TO NEAREST <br />WELL T <br />R FOUNDATION4a�,t _,__..,.. Cl PROPLRTY'LINE <br />O DISPOSAL PONDS WIDTH <br />ft LENGTH _ <br />R DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION 11 PROPEKT'Y LINE ft <br />❑ SEEPAGE PITS <br />WIDTH <br />It LENOTR <br />_ ft DhIml _ 11 <br />DISTANCE I'O NEAREST <br />WELL <br />ft TOI iNDAT ION A PROPERTY LINE R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORT( WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. <br />STATE LAW'S AND RULES AND REGULATIONS OF SAN JOAQUIN COL NTT. <br />NINL 'M N HOUR ADVANCE NOTICE REOLIRED FOR INSPECTIONS- PLEASE. CALL 1209) 9<3-7N97 <br />SIGNED_ _ 1 T_7 TITLE---Cr�VI �- {}i'� DALE (� a <br />PE SC Received Ch -Il Amount Dale pernilti Invoice Permit IDN <br />Cade INFO B ash Remitted <br />'M21 "() a b <br />1::2 C�2 ONSITE. WAS rt. W ATf.R PERMIT <br />/y <br />