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A�q <br /> • ONSITE WASTEWATER TREATMENT SYSTEM PERMIT - <br /> SAN JOAQUIN COUNIY ENVIRONMENTAL HEALTR DCP 304EWEBERAVE-3"AFL-STOCKtt CA95202 - (209)968-3'120 <br /> NON-REFUNDABLE PERMIT ALL(209)95b'7697 INSPECTIO TS EXPIR l YEAR FROM DATE ISSUED <br /> JOB ADDRESS CIrY2m <br /> CR054 STREET APN • V 9 PARCELStM!Ko M <br /> PpO <br /> OWNER NAME IVA .I/ -e-2 PHONE 0 <br /> GWNFR ADDRC44 ,�J-� � „JF��/Y2 lI r CITY/$FATPJZIP <br /> CONTRACTOR PHONE <br /> CON'IYACFORADDIIP9B CITY/STATPJEIP <br /> LILLNSE ❑C-42 OC-36 OTHER NUMBER EXPIRATION DATL <br /> WATER TAIRE DEEM: ft CEOGRAPBICALINPORMATION: CGOYMOrRr X Y <br /> ❑ FERC TEST(S) NUMBER LANDUSRAPPLICATION9 <br /> TYPE OF WORK: D NEWINSTALWTION ❑ REPAIRAODTON ❑ ENGINEERDESIGNED/ALTERNATI' v <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTWWRVE: PES.ENC. COMMERCIA 13 OTHER <br /> NIT:_ _ <br /> / NUMBEROF BEOROOMSI NUMDEROFEMPLOYEES: <br /> SEPTIC TANK TYPE/MFG .� -CAPACITY pl k OF COMPARTMENTS_171> <br /> Cl GREASETRAP TYPE/MFG CAPACITY $01 XOPCOMPARTMENS �--q <br /> O T:PKG TX PLANT DISTANOETONEABPEWELL R FOUNDATION R PROPERTY LINE /J• V R <br /> ❑ LIFTSTATION SHE TYPEOPPGMP ❑ (SANDOILSEPARATOR(ENCIASRDSYSTEM) <br /> LEACH LINES LI <br /> LEACHING CHAMBERS XOF LINES LENGTH OF LINES 4--o[ R <br /> ��v� <br /> DIBTANCBTO NEAREST WELL �fl FOUNDATIQV_� ft PROPERTI LINE /-S V ft <br /> ❑ FILTER BED WRITS 0 LEHGTH R DEPTH ft <br /> DISTANCITONEARBST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIMH ft LENGTH ft DEPTH R <br /> DIFTANCR TD NEAREST WELL R FOUNDATION ft PROPERTY LME R <br /> Cl SUMFS wIDTN It LENGTH R DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTYLINE I <br /> ❑ DISPOSAL PONDS WHITS R LENGTH "F' ft DEPTH fl <br /> _ yyyFFF DLSTANCETO NEARS WELL _ft FOUNDATION R PROPERTY LINE R <br /> /l(y SEEPAGE PITS WOTH R LENGTH ft DEPTH R <br /> DIDTANCETO FAKERY WELL_Ie-6 ft FOUNDATION ft PROPERTY LINE D R <br /> I HERBBY CEMFV lrVAT I HAVE PREPARED THIS APPLICATION AND THE WORK W ILL ISE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OP SAN JOAQUIN COUNTY, <br /> MINIMUM HOU ADVANCENOTICE REQUIRED FOR INSPEsCTTIONS-PLF-ASE CAIJ.(KN)955-7697 <br /> SIGNED _ TITLE DATE <br /> �/ DATE <br /> f It <br /> 14 <br /> r N <br /> 1 _ <br /> r <br /> J _ <br /> O^ I <br /> r <br /> r <br /> 71 <br /> O <br /> DEPARTMENT USE ONLY -1 <br /> ' ApplicaUaim AccePled B •�� DBu A. EmpI.yeelDX_ 1-1=4_ <br /> Heal lnrPeclioo a D.I. LZ—•C5—6 E3 SPECIAL PERMIT-Appmved by <br /> Ch.MCHr Of SoHW fi�Ft: PIUSDDIp Soil Cluncur; <br /> COMMENTS L4' �SeNe� -- <br /> bpi' aeG♦i G.Qhs <br /> PE SC Received CheCWN Amount PermN/ <br /> Code Irvro B • ReMtl9d Dat Sery UenU InvaiceX Parmi11D0 <br /> V <br /> GO358LPh <br /> .:-01-001 <br /> 1v2ro2 ONSITE WASTEWATER PERMR <br />