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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON11AFNT.4L HlfALTH DIV15SON <br /> 304 E.WEBER AVE,3"D FLOOR,ST(XKTON,CA 95202 1209)46&3420 <br /> - NON-RE F}UN�DARRLF PERM IZ. I S I Y R F' a Dom) 'l.'CFD <br /> ' 178 ADDRESS1 Z7 <br /> n/ L G —��Y.'c"''��✓'�`v,/�)[��..., <br /> CfTYfL[P ------PARCELS <br /> l'%FJ.4PN <br /> OWNEP.NAME4::�A!P ADDRFS5 ...�----- <br /> ' C1TY2IP� tt pifGNE <br /> C.OYTRAC_CO�R 4 _�--�� ES • N wv <br /> CITY27P PHONE_ M t� <br /> GEOGRAPHICALMFORMAT7ON:COORDIANTES: X_"Y______I'OWNSHIP_RA'.VCE�SECTION_PEYCE 0 <br /> 7-'Ic�VL-VCL./ <br /> PERC MT(S)( )HOW MANY APPLICA'T10N%:__ _ p �y{� <br /> TYPE OF SMIC WORK. 13 NF.W INSTALI kllON X REPASRIADOMON 17 DESTRUCTION SEP 6 2000 <br /> INSTALLATION WILL SP.RVF: ❑RESIDENCE ❑COMMMCIAL ❑OTHER co{jNTY <br /> NiIMBER OF£`IPLOYF.ES PUBLIC HEALTH SERVICES <br /> 'NUMBER Of LIVING URfi:S:_� MB/ER OF BEDROOMS:—_ },wIIR`OUENTAL HEALTH DIVISION <br /> CHARACTER OP SOD.TO A DEPTH OF 3 FEET. ".! " PTTIAUMP SOfi.CHARAC'TER:� _J=y ATER TABLE DEPTH <br /> Ci SEPTICTAN&GRE.4SETRAP fYPF1MFG_._4.�-. __(APACITY_ NUMBER OF COMPARTMENTS <br /> DPKOTREATMENT PLANT DISTANCE TO NEAREST: WELL.__ FOUNDATION_. PROPERTYLINIF <br /> QI.IFTSTATION SIZE_____,_„_ TYPE OF I'[IMP __SAND OIL SEPARATOR tENC'I.OSEDSYSI MI <br /> LEACHING LINE NUMBER&LENGTH Or LINIS_) - I �.+!�X�//1111� <br /> 1)NFILTRATORCH NC <br /> I <br /> DISTANCE TO NLARLST• WELL:9_0 FOL'NDMION „?ROPERTY LINE <br /> D MIXER BED WIDTH LENGTH _ DEPTH <br /> j DISTANCETO NEAREST:WELL_-- FOUNDATION:_ PROPERTYLINE <br /> C3 MOUNDED WIDTH LEND T)I DEPTH <br /> D7STANCETO NEARTST Wt1L f FOUNDATION__ PROPERTYLINE___ <br /> SEEPAGE PITS WIDTH +SQL LENGTH i__01"PT11 y �rA�/�/ <br /> DiSTANCETONFARE.YT: WELL FOUNDATION �O [ PROPERTY LINE •v <br /> ❑SUMPS WIDTH LENGTH D[P7I1 <br /> DISTANCETOKEAREST. WELL __FOUNDATION PROPERTY LINE <br /> E3 DISPOSAL PONDS WIDTH LE:40 CH—._—DEPTH <br /> DISTANCE TO NF:ARISST: WELL FOUNDATION PROPERTY LINE <br /> I HEREB1Y ERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DO''IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN('�LSt►%PP LA , IHD ES N REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ' SIGNED: �r�/J r�7y�t j✓ TITL DATE <br /> LI <br /> f i <br /> � <br /> DAM ow <br /> ; <br /> i � <br /> MAI I <br /> R I <br /> FT f <br /> _T_ I <br /> It DEPARTMENT USE ONLY <br /> APPLICATION ACc:EPTL+D HY: v_ DATE <br /> TANK PIT,OR SUMP))NSPF:C�IED�"f8!Y�/--_ <br /> FINAL MSK'C�TIO�,N pYN,r <br /> CbhLAfBNT S: ► _ 1S it31 tt W r !R <br /> 4 PECOOE SC + AMOUNT CHECK IINr a(ICEIVU)BY DATE: ('11SERV10E 0.FXjUFST. SEPTIC ID. <br /> +NFO RFM7TTET <br /> I 2.t0 1 L5, ISO"' 3 t[ L <br />