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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUN7Y PUBLIC HEALTH SERVICES FNV[RONMLNTAL HEALTH DIVISION <br /> 309 E.WEBER A VE.,3R0 FLOOR.STOCKTON,CA 952-D2 (20914u-3420 24 H i'j4D-F1C - <br /> N-R FIN ABLER:NIT E'PIRFSI YEAR FROM DATE ISSUED FRE IBES-ra0 <br /> iOB ADDRESS 1 PF <br /> �dr7 G I .1 FQ R A L_L_, <br /> c17Y2IP (.D[X�• l]c.-�D PARCHL SIZFJAPN � G 7'N S F <br /> OWNER NAME )401&f" - ADDRESSp— <br /> CJTW/.m_ __PHONE. f — <br /> CONTRACTUR /�p`�f"���" D ADDRESS 2– �• ^C►& / <br /> C[TYlZ[P UT's 'Z Z PHONE <br /> GEOGRAPHICAL INFORMATION:CUORDIAN`rES: % Y TOWNSHIP--RANGE_SEC7I7flN_____ <br /> PERC TF41(S)( )HOW MANY APPLICAT(ON N: _ — <br /> TYPEOFSFPI'ICWORK: IF.W INSTALLATION ❑ REPA[RlADDITION D DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIOENCE 0 COMMERICIAL <br /> NUMBER OF LIVINGUN[TS:__ NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES:__ <br /> CHARALTIiR OF SOIL TO A DEPTH OF 3 IRF'F:l':_ PIT/SUMP SOIL CHARACTER: _ WATER TABLE DEPTH <br /> CTANK/GREASF:TRA[' 7YPE1MPCi T� CAPACITY1�o NUMBER OF COMPARTMENTS <br /> ❑PKCTRFATMENT PLANT DISTANCE TO NMR.P-C WELL,y FOUNDATIGV.�_ PROPFATY LINE�� ^ <br /> ❑LIFTSTATION SIZE TY PF OF PUMP SAKD OIL SEPARATOR(ENCLOSED SYS'I?M) <br /> Vd4EXCKINGLINE NUMBER&LENGTH OF LTNI_ti_,1 / Z10 I INFILTRATOR CHAMBERS <br /> DISTANCE TO NCARtiSt': WELL > FOUNDATION �D ._'ROPERTY LINE 2G� <br /> ❑FILTER BFD WIDTH L FAIGTH 1)1{PTH <br /> DISTANCE TO NhAREST: WELL FOUNDATION:_ PROPERTY LINE `1 <br /> i <br /> ❑MOUNDED WI 7171_, LENGTH ._DEPTH _ <br /> DISTANCE 70NEARL•S7': WELL FOUNDATION _PROPERTY LINE m <br /> FPAGE PITS WIDTH ? I.FNCTTH Do" <br /> DISTANCE TO NEAKECT: WELL FOUNDATION PROPERTY LINE <br /> ❑S(!•14P5 WIDTH LENGTH DEPTH <br /> DISTANCE'10 NEAREST: WELL _�FOLfiDA710N PROPERTY LINE <br /> r <br /> ❑DISPOSALPONDS WIDTH—__ LENGTH ,DEPTH _ <br /> DIS 'CF.TCS NEAREST: WELL „_FOUNDA770N PROPERTY LINE• <br /> I HERE CER T HAVE F.PARED CATION AND TYE WORK WILL.HE DONE 1N ACCORDANCE WITH SAN JOAQM COUNTY <br /> ORDI FC,STA WS, 'D ES RC. ATIONS OF SAN JOAQLIN COUNTY. <br /> SIGN _ TITLE: _ <br /> DATE: <br /> I <br /> IF <br /> I <br /> L <br /> I � <br /> i ; I <br /> it <br /> I <br /> � I <br /> :AN .u. <br /> FH PARTMRNT UTE ONLY 'cNViF10NL1El`I�.I FicF:• n ,+ <br /> r <br /> APPLICATION AGCSnFn HY: - .-- _-- _pATF_• -- . <br /> TANK,PR,GA SLMP f�SP[ BY: _ .__QATF <br /> F7NAL LYSPBCfIOS BY. ��17 <br /> ` <br /> COMMENTS'-, ------ <br /> PECODE SC AMOUNT CICAl KhChIY©BY DATE PERMIRSERVICE RE(jlIFST S SEPTIC LD* <br /> MR) R• _ CASH <br />