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LIQUID WASTE PERMIT 21 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IIFALTFI DIVISION t .2e. ( ,T- Li <br />304 E. WERF.R AVE, 3"" EI noR. S MC icroN, CA 95202 (209) 46S-3420 r: 4.1;1 <br />NON-REP:IN AJILE PERMIT EXPIRES I. YEAH FROM DATE ISSUED I N :Si 1 :#11:; C;1- i -( 'IN, .-.) <br />ion MAW SN_c:21. in N . ei "64+ -ezcl.. i 001- 2.....o- ?,trr ,,,,,z,p . zfiy1 . q6 cc PARCEI SIZEJAPN .--.., <br />OWNEKQJNAE b #, 0 b( e. 40 r, -ea-.. ADDRESS trt/S & Ail (4131N 5+-• <br />CITY/in 1-i.e.le 0,,,,ef /g 9- ',Ho.: 7017 ) r.1 <br />cONTR AC i:074.a t .k 5(11. ONS AnDREss_q(200) 14 - LIN 156n 1A)1411,- <br />area...11,5A rbizA-,...„, qg-doS"--- PHONE C1.2eq 4101.0 914 7 <br />GEOCRAPHICAL INFORMATION: COORDIANTES. X se, _ . TOWNSHIP _RANGE_SECTION_ _ <br />PERC TEST(S) ( ) ilOW MANY vev,,,..yytgoN <br />TYPE OF SEM'. WORK. 0 NEW INSTALLATION y REPAIR/ADDITION r" 0 DESTRUCTION <br />INSTALLknON wiLL SERVE XRESIDE_NOE: LI COMMERICIAL CI OTHER <br />NUMBER oF L(VINC UNITE NUMBER OF BEDROOMS. NuMHER OF EMPLOYEES .: <br />CHARACTER OF M)1. TO A DEPTH OF 3 FEET PIT/SUMP SOIL CH.ARACTESc WATER TABLE DEPTH <br />CI SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br />0 PEG TREATMENT PLANT DISTANCE TO NEAREST: WTI L FOUNDATION PROPERTY LINE <br />0 LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />0 LEACHING LINE NUMBER & I TiNEMei OF LINES INFILTRATOR CHAMBERS PAYIVI EN I __I <br />DISTANCE TO NE:AREST WELL FOUNDATION PROPERTY LINE RECF_ I \ i'Er: .„..... <br />0 FILTER BED WIDTH LENGTH DEPTH <br />1 1 1 0 1 2091 DISTANCE TO NEAREST: wrt.t.. FOUNDATION PROPERTY LINE <br />0 MOUNDED WIDTH ..„ LENGTH DEPTH SAN JOALAJIN COUNTY __PUBLIC HEN TH SEMMES <br />DISTANCETO NEAREST: WELL FOUNDATION PROPER T4 T.I • NMI,Re.__±,1_..A LII TS r 'VW", <br />Li SEEPAGE III IS WIDTH ,, ... LENGTH DEVI'm <br />DISTANCE TO NEAREST! WELL FOUNDATION PROPERTY LINE <br />0 SUMPS WIDTH LEFIGTH DEPTH <br />DISTANCE TO NEAREST: WELL PROPERTY UNE: _______FOUNDATION ____ <br />I:1 DISPOSAL i'ONDS WIDTH _ I.ENGTH DEPTH <br />DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />I HEWER V CERTIFY THAT I HAVE PREPARED TH APPIACATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDIANCES, STATE WS, AND Lity AND 'LATIUM; OF SAN JOAQUIN COUNTY. <br />, / ,,,,...,- SIGNED' TITLE) DATtk-119 ) <br />-I i <br />-Fitie----1 <br />is <br />• <br />_ <br />4-AP-kikk G I k D <br />APPIACkTION AOCUTEO BY _ 4..,41M+I ..10. <br />NT= oed.V <br />DAM <br />PRN K. PIT. OR SUMP INSPECTED BY: 1 _DATE <br />HP:AL impECtioN Br <br />C°MMEN7S44e4a) MdfLe.' illght. 1 1Q. L../ ,C) I CtiLteRt S 9 .... _ <br />PE '_`ODE <br />_ <br />iNWr AISOuNT <br />14 6N,I ITIF ITHIRIM <br />ekEoR <br />CASI4 <br />WEAVED NY <br />f ID-'111=r10/JAW,WHAM111N4 <br />DATE WTISERVIC SI-.1,1'1I. II <br />lp 10 rinkw