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ONSITE _...ASTEWA'TER TREATIMEN'Ir-gMEM i, ..XvI IT <br /> ANJ()AQtJN COUNTY ENVIRONMENTAL HEALTTI DEPAHTmENr 304E WEBER AVE-Y"FL-STO(:KmO CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)9$3-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JoaADDRrS.S ONeu, CnvruP �[y�tSO`�c'a O <br /> CROSS SMEFT .N C1 <br /> AP3 -1 3Q I-727 <br /> ..-.,�` PAstcul.STii.-G��qJ <br /> OWNERNAME PHONE <br /> OWNER AnDRFM CII-YMrA'r17:61P <br /> CONTRACTOR PHONE. <br /> CONCRACI`OR ADDRESS C1IYISTATEIZIP <br /> LICENSE 0 C-42 Q is-36 OTHRR NCMSEH <br /> EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOMAPHtCALINFORMATION: Coordinatci X Y <br /> I] PERC TEST(S) NUMBER LAND USE APPLICATION N <br /> TYPEOF WORK: NEW INS'1'ALLKFION ❑ REPAIRIADDInoN ❑ ENGISk:F.R DESIGNEDIALTERSATIVE <br /> ❑ - REPLACEMENT Cl Dr-mmCTION <br />' INSTALLATION WILL SERVE: RESIDENCE ❑ CORIMERCIAL ❑ O'"IER T <br /> �K NU><1REROFLIVING UNITS: I NUMBER OFBEDROON5: ry NUMBER OFEMPLoyers: <br /> . SEPTICTANK TYPE/mro tq ,-jte.N_ CAPACI'FYP1 NOFCOMPARTNENTS f y <br /> Q GRLASETRAP TVPFJMVC CAPA(711Y gal #UPCOMPARTIENTS `.nJ <br /> '� S I'' <br /> [357 <br /> PKC TX PLANT 'D1 'All(:E Tp NEARESr: WELL y/��..w �- ft POUNDAIIOv ti PRnPI:RrY L1Nr. <br /> ❑ LIFT STATION SIZE Tx-PE OP PUMP ❑ SAND(RL SEPARATOR(ESCI.OSF.D gvsTEM) <br /> fQ LEACH LINEN ❑ LEACHING CHAMBERS #Dt'Ll::u'ti LENGIHGI'LINES_ 7� <br /> DISFANCETONEAREST WELL PR(MERIYLINE it <br /> 13 FILTER RED WID-M fF LENGTH H I)r mT _ fl <br /> DISTAwmTONEARLCI' WELL fl tX)I1%'DAMN H PROP1'RTY LINE <br /> ❑ MODNDED WmTH fl LENGTH ft DEPTH Il <br /> DevuNCETO.ItE*A�REST WELL X11 FOUNDATION ft PROPERTY LINE H <br /> 71 SUMPS WID71t _ms-^µ _ _R LENGTH R DEPTH /I� ti <br /> DISTANCE ToNEARL4r WELL l!J fl FOVTDATION� fl PROPERTY LINE/^_ tl <br /> ❑ DISPOSAL PONDS Wim ft L Fw,-nI ft DEPTH fl <br /> DISTANC'TONEARLST WELL fl FOUNDATION fl PROPERTY LINE. Il <br /> SEEPAGE PITS wipm flNGTH _ft DEPTH R <br /> r - <br /> �DISTAW:ETONEARFST WELL -'DATION R PROPERTY LINE fl <br /> E 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WFFH SAN JOAQUIN COUNTY ORDINANCES, j <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. fl <br /> .IMUM 241 HOUR ADVANCE NOTICE REQUIRED FOR 1NSPIA-170NS-PLEASE CALL(219)953-7W7 <br /> SIGNED —- TITLE ^2— DATFL 4Z,, <br /> 1� <br /> CICAUUM !E <br /> I <br /> J <br /> L <br /> OF <br /> no 1 NT <br /> A li <br /> I Bn 8'niN r an t4i A <br /> �- •: - <br /> 5COMPT <br /> I lilt <br /> Ll <br /> r <br /> j I DEPARTMENT U.' ON I <br /> Application Accepted B e Date ^ Area Em lD ce IDN T_/ <br /> 1..� P Y <br /> Real Inspection By Date ❑ SPECIAL PERMIT-Appmved by <br /> Character of Soil to Be or3 Ft: PRIAmp W1 C�hlaracter: <br /> COMMENTSi P - ( <br /> �C I Y2.4 F� 4'� L'kl t`T_.. r U _. _' <br /> /;Y /4 !r //'••• 4 -L• <br /> PE SC Recelved ccldN_ Amount Permit/ <br /> Code LEVO B s RemittedDate Se"I..R gcstA Invoice# Permit HIM <br /> jib. 10 15 <br /> W10 <br /> i2fLH2 ? � �� ,SpjLl•�ur ,� /G42- I,OGI /.401C* ,Z 0 4GL.00X '9lSTF.11'ATER PERMIT <br /> 70 <br /> ���.,aJ ._J <br />