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1 ...�I gg ya ..., l a� t( Y^9�i V i,.., F -F a �Cii g g�I� �� <br /> ne ,7.'�',.� ti._ .$.. -1�'h.f ., /} , r,..S n ., �.0 Vk �I '--,p iT�:N 7 <br /> SAN JOACMIN COUNTY ENVIRONMENTAL HEALTI1 DEPARTIVlEN'f 1868 E.HAZELTON;AVENUE-STOCtt T ORI CA.95205-(209)468-342..0 <br /> NON-REFUNDABLE P--EF-11-1T------- -- _. _ - \----- ----F_O_R—MIS-P-C--T IONS EJ +I?EJ_( YEAR QFR <br /> ORi ?6T=ISSUED <br /> JO[ :DORISS .y2 - p /`" L0!bt <br /> �pC.� N ! s� <br /> �p V_ <br /> q -- -- <br /> CROSS STREET —( r c.c� FS l SIZE <br /> _ <br /> -- -zt -- ----- - /1f f\.__ —_ PARCEL SI.E <br /> Olt+NIER NAME r,PJlr:�l`�C\.S �..__.Y2�\V c"Z —f I-IONE �(_Zz <br /> nWNL:I:ADDress .. 7 _ J'�!1-A R� InO ��— _ ` CITYISTATEIZ.IP _rj O(, N C� q 1 <br /> CoPITrACToR Q� PHONE <br /> ':Op.l'iF,ACTOR ADCq$I3.SS CIT'(/:z-,TATE/ IP <br /> LIOLaNSE I.11IG-42 01IC-;36 OTHER'___._____ MuRnrER­_._ _E01PIRATIONDATE-.--_--- ----- <br /> YfATER TAF-=LE DEPTI-I:_ _ ft GEOGRAPHICAL.INFORMATION: Cr001'Cii ll�t@v Y <br /> F'f;RG TEST ;t- f (UII_DING;I'cRIMIT Z,`— w'_-- 'A! T)USE APPLICATION# <br /> Ts`r'E F1�/OPl4: NEWiIUS'iALI-.ATION � U(q� l:! REPAIR/ADDITION - - 11 ENGINEER DESIGNED/ALTERNATIVE <br /> idE:PLACENIEn.I'I s i' (?IT—OF—.SERVICE SEPTIC SYSTEHlI L DESTRUCTION <br /> !I))STAE.1_ATION)All IL SERVE: ESIDENCE 1_I COMMERCIAL (] OTHER <br /> NUMFIER Or LIVING UNITS:- NUMBER OF BEDROOMS: <br /> NUMBER OF EMPLOYEES: <br /> D SEPTIC TANK TYP UNIT-r •_—.- - —_-- GAPACITY /� - gal #OF COMPARTMEnII-C <br /> MJ_ GREASE TRAP 7YPrrMFC� .----_-------- _ CAPACITYttt---- - - gal #OF COMPARTNIEPITS - <br /> DISTANCE TO NEAREST: WELL �^ ft FoumDATION---. ft PROPERTY LINE —_-- ft <br /> (-.i IJF T STATION SIZE ---_-- _TYPE 01=PLIAIIP-`_.--- Cl PKG TX I'LAM T I-T, 5A ID OIL SEPARATOR(ERICLO SED SYSTEM) <br /> J�1�1-EACH LINES I,.! LEACHING,CHAML1El?S- --__ #I(.)I I_IhlE-s�- LENGTH OF LINES SCJ C - ft <br /> j/ <br /> DISTANCE To NEAREST WrLL-��(9 fi. FOUNDATION /� ft PROPERTY LINE — ft <br /> (-a FILTER t EI.) >nnnTrl ft I_ENGTI I _ ft DEPI-I-1 - <br /> DISTANCE TO NE.ArEST WELL ft FOUNC)A'I'ION ft PROPERTY LlPlli`- _ ft <br /> C:`" 11fl(:)U�IDGD ULIID'I'I-I _ 'ft LENGTH _ - (t--- DEPTH__ _ ---_._- -_ ftDISTANCI TO NEAREST WELL- ft FOUNDATIi)N _ _ fl: PROPERTY LINE fl <br /> ht sumps 111/IU'I'H ft LENGTH --_- ---- fi DE=PTH ---- fT <br /> DISTANCE TO NEAREST WELL. ft FOUNDATION ft PROPERTY LINE ft <br /> DISPOSAL PONDS IIIII(im ft LLNt;.N-i fl -- DEPTH ft <br /> DISTANCE TO NEAPES•r WELL it FOUNDAT )N fl PROPERTY LINE _ ft <br /> f-'iT:> NUMBER _ llllip'TFI------ 'I ft 11GP'1'H <br /> - _ -- -- <br /> DISTANCE TO NE-ARE sT WELL ft FC)UNPATION It PROPERTY LINE ft <br /> I I EREDY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TI-IE WORT,WILL BE DOME IN ACCORDANCE••WITH SAM JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> >r <br /> '..._M14-41hifo,?p_r` �F`�6i,�C 1��'�c�lt�f'�"�(�8�f�n tl t��kF?/t�( C'���lw�!!� ��P rT/�`_?e:��F_�-�2{rg 9, t�;s�y�7 p� <br /> SIGNEE) oa� — _ TtTI E -- DATE 6- 13- l/ <br /> I � <br /> tE <br /> -- -�_---- ---- ---- --- — ---- _ -- -------..-- — – ---I J A U <br /> 11 M <br /> HI EF r_R M N_ <br /> --— <br /> It <br /> A17f)liG<?tl(>Yl Accepted[3y Area �- _q Employee ID'1tf <br /> Fir=;i Ilra,eri:IUn t3;+ -- -- Date--- _ � D :PECIAL a ERMIT-Approvecl by <br /> ;la rat;i:rr of`foil to D tfr of 3 F . ---__---- Pit/Stttnp Soil Character: _ -- -__-- <br /> L <br /> TSF SL: Receiarecl CI)eek#! !`,no, f'etmitl tttvaicedl. PermiilD#i <br /> oats, <br /> Coe" INI O_ E3 Cas F. )tttec3 Service Request# — -.- <br /> rI,I ONSITE_WASTEWATER TRTMNT SYSTEM PERMIT <br /> dltill'� <br /> t� <br />