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LIQUID WASTE PERMIT <br /> SAN IUAQUIN COUNTY PUBLIC HEALTH SaRVICTS ENVIRO�L\(F-N'TAI.HEALTH DIVISION <br /> 300 E.WEBER AYE.3-Ia.00R_STOCKTON,CA 95202 (209)368-34m 2.44 H R <br /> // [7�C'�/ NON•R F II)ABI 'PFRMTTFk IY'AR MDA S'TI) <br /> L. ! 7 <br /> l0B-Af)08ESS„_//, e fj/ 1�/ -��+ <br /> CI'TYlLIP ' Q'o , C /J_ _PARCr1 SIZFJAPN�^r—• 1-r r V 5��D t'-C t-1 t <br /> OWNV.%AMIi�2fy_�E� �� ADDRESS_ <br /> C1TY!/.II'_ �) PHONE <br /> CONTRACTOR /rte�J N AllDRESS <br /> CITY/ZIP C PIIONE "� <br /> GliOGRAPHICAI.INFORMATION:COORDIANTES: X Y TOWNSHIP__RANGE_ ECTION__ <br /> PF.RC TNIMS)( )HOW MANY APPLICATION 0: <br /> TYPE OF SEPTIC WORK: ><NEW INSTAIJ A'DON ❑ REAMIADDITION E3 DESTRUCTION <br /> INS'CAIJATION WILL SERVE RESIDENCE O COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS; NU.MII H:R Of REDR00MS:- NUMBFR OF EMPLOYEES': J <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET• , PI,rm:MP SOIL CHARACTERt —*;/� W ATF.R TABLE DE1'I tw& <br /> 'TANKtcRHASF'TRAP TYPEMFG C'APACITYfi+�0 NUM UFR OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE T'O NEAREST. WELL FOUNDATION PROPFA Y LINE . <br /> ❑LIFT STATION SJZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM!_ <br /> .1I/LA(:IIINGLINH VUMBhR&I.F_NGTH(h'LINES /-� INFfi.TRA7'OR CHAMBERS r <br /> `/� DISTANCE TO NF.ARUT: W'F1A. FOUNDATION ._.P'ROPERTYLINE /rte” <br /> �FILTER BE) WIDTH LENGTH DEPTIi _ .G <br /> DISTANCETO NEAREST WELL FOUNDATION: PROPERTYIANE <br /> ❑MOUNDED WIDTH LFNG I'H DEPTH C <br /> r DISTANCE TO NEAR= WULI, FOUNDATION PROPERTY LIRE <br /> AGE PITS WIDTH LENOTH _DEPTH -2-50 <br /> DISTANCF.TONHARET: WELL FOUNDATION PROPERTY IIKE_ <br /> a SLNIPS WIDTH LENGTH DEPTH__ T <br /> DISTANCE TO NEAREST. WELL r0L;NDATiON PROPERTY LINE <br /> ❑DISPOSAI.PONIIS WIDTU I.F;NG'I'H_ DEFTH <br /> DISTA. �11 <br /> FOIINDAYION PROPERTY LINE <br /> 1_ <br /> I HEBEBE�N <br /> .PREP HL!A.�fl..CA� -DTHF'.FORK WELLBEUO.N'E N ACCORDANCE WITH SAN]OAQUIIV COUNTY <br /> ORDtAN ULBSA OF SA N.IOAQ!AN CO ON TY, O <br /> SIGNED: T[TLE: s DATE: 0 <br /> 7­7 T 177 <br /> � f I <br /> i <br /> FUR R USE.UNI'v <br /> APPLICA'OON ACCFMO SY: It __ DATESIv <br /> TA_VK PTi.UB St:MP 1NSPECTED BY: <br /> PIAAL INSPSCMNeB�Y: p <br /> (:OMMENfS':.]��f /� Am C'u ft ,—V,5 1S __— 2 P0ragA " <br /> PE CODE $L` AMOUNT RWEVE)BV DATE PF 117SFRVIC.E REQLTSTT SEPTIC 160 <br /> INTO REMRTED J1SH <br /> Aw <br /> a <br /> -Rdll2zi <br />