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19 LIQUID WASTE PERMIT <br /> SAN JOAQCIN COUNTY PUBLIC HEALTH SERV ICES FN V IRONMfNEAL HEALTH DEVISION <br /> `✓_ 101 E.WEINER,AVE 3"FLOOR,STOCRTON,CA 95202 OWI 0R-T420 <br /> Y NON.RF,FUNDABLE PERMIT EXPIRES I YF.ARFROMD TE INRURD 'r <br /> fOB ADORES$ /1 APN X730 b Z PARCELSIZE: / Y143 <br /> CITYlLIP. F�-�/_.`/ _ BCILOMG PEAMRY <br /> O\\T'EA NAMkYS P./ Ic�y R.P A{. ADDRESS______ <br /> CITV/ZIP ( �J PHONE NUMBER <br /> CONTRACTOR�Yr_U �_�Qj OIT �YA ._._... ._._ ADADDRESS <br /> CTSY/LIP C)�`�k-'l PHONE NUMBER <br /> GEOGRAPHICAL INFORMATION: COORDINATES:%_, Y TOWNSHIP RANCE SECHON „ <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> ❑ NEW INm <br /> STALLATION � RESIDENCE ee <br /> NUMBER OF BP.DROOMS: aL- <br /> REPAIWAUU1TlON ❑ COMMERCIAL <br /> ❑ OTHER NUMQFIROFEMPLOVEKS: <br /> EERBDiALTERNATNF. <br /> CHARACTER OF SOIL I'O DEPTH OFI': PIT/SUMP SOII.CHARACTER: W'A'TER TABLE DEPTH: <br /> ❑ PENCTESTFSJ HOW'MANV APPLICATION#__ <br /> ❑ SEPTIC TANK TYPE:MFO CAPACITY #OFC'OMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY #OFCOMPARTMENTS <br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION_ PROPERTY LINE <br /> ❑ LUTSEATION SIZE TYPEOFPUMP SAND OIL SEPARATOR(ENC LOSCD SYSTEM) <br /> ❑ LEACH LINE #OF LINES:_LENGTH OF LINES:_ o11e 1.n. T; WELL FOUNDKUON PROPERTY LINE <br /> INFLITRATOR CHAMBERS: <br /> O FILTER REO WIDTH_ LGIOTH UFYTH_ DScwC,,,mF.O ; WELL— FOUNDATION PROPERTY LINE <br /> ❑ MOFNOED WIDTH_ LENOTH MITI_ o1rtTmC[iO rvCARLeF; WELL_ FDONDATION PROPERn LINE <br /> ❑ SUMPS WIDTH LENGTN DEPTH olmpCrtVnFAnui; wFLI FOUNDATION_ PROPERTY LINO <br /> ❑ DISPOSAL PONDS WIDTH LMOTH DEPTII DDEANCEMNEAADC WELL FOUNDATION PROPERTY LINE_ - <br /> ❑ EEEPAGE PRS X DIAMETER DOTH DiRINCETOI4.: WELL FOUNDATION PROPERTY LINE <br /> I HEREHYCERTIFYTHAT I HAVE PREPARED THIS APPLICATIONANDTHE WORK WILL BE DONE IN ACCORDANCEWETH SAN JOAQUIN COUNTVOADINANCHS,STATE LAWS C� <br /> AND RULES AND REGULAI IONS 01:BAN JOAQUIN COUNTY_ <br /> "/J� MINIMUM 2</HOUR�(1)VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALLQ09)CAR-JA2J <br /> - 7CNF:D:�_Y-fL L�bc��5�-, Elft KO TITLE;g5L4' IajA XL!�. DATR:3;/6-D,Z <br /> J <br /> wHusl G if i�*HP <br /> 1 7 � I I � T A �. �__1 i 1 � I � __ _— <br /> 1 r <br /> — <br /> DEPARTMENT UJIF.O .Y ��3 E y <br /> APPLICATONA TGB BY: DA EA EMPLO E10 DIMRI LOCATION <br /> INSPE(TEORY:_ DATE <br /> PER MR ETNA TF3 DATE: INSPECNM: <br /> PE C:IDR YNPO AMDNIT EI: AFGEYTO DATE IVOUThERVICERIQCDT0 IMV ICEY SEITI<ILP' <br /> .EMI. BY <br /> I <br /> RRvneo�Lwl �' <br />