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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 344 E.WEBER AVE.,3"D FLOOR,STOCKTON.CA 95202 (209)468-3420 <br /> NUN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V' !^�J9 /Cj ��i +] .. Lam' <br /> _ <br /> CIT`.'/ZIPr►L�Y1.� '4� YJ3 V PARCEI_SIZEJAPN R ` <br /> OWNER NAME YN P + -%0y) ADDRESS <br /> CITY/ZIP_ yys� PHONE S <br /> CONTRACTOR �.'(!�e ��"�i ����` ADDRESS <br /> CITY/Z[P� art¢G-c✓} G1,/ 53 3� PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPJRANGE SECTION <br /> PERC TEST(S) ( ) HOW MANY - APPLICATION k: <br /> 'TYPE OF SEPTIC WORK: i SNEW INSTALI,ATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: &'I-S[DENCF ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS-_r NUMBER OF BEDROOMS: *3 NUMBER OF EMPLOYEES:__ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: �- PIT/SUMP SOIL CHARACTER: _ WATER TABLE DEPTH <br /> Q'SEPITCTAN KIC7REASETRAP TYPEJMFG ` ` CAPACITY 12,aO NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL_100 FOUNDATION InT PROPERTY LINE <br /> ❑LIFT STATION S[7£ _ "TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) - <br /> B'CEACHING LINE NUMBER&LENGTH OF LINES 9 INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: W ET.L It C297 FOUNDATION 91D f PROPERTY LINE -76 <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: W ELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DI STANCE TO NEAREST. WEL1- FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE['TTS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUNIPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DF.1 TII <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LI NE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQ7AN COUNTY. <br /> SIGNED: u'A', TITLE.:CibN.�-/`ebf o� DATE: <br /> -ter <br /> O <br /> F <br /> sp,4 <br /> .Qka <br /> I r <br /> OF- <br /> 1 vp <br /> 77-1 1 <br /> vll� i I I::)1��"rS I . i I I I <br /> I t <br /> FOR D RNT USE ONLY 3(��J, [a�(�J <br /> APPLICATION ACCEPTED BY: - ` _ ` DATE: !'`v <br /> TANK,PIT,OR SUMP INSPECTED Y: 71 4 <br /> FINAL INSPFt-"TION BY:44 <br /> COMMENTS: <br /> PE CODE SC AMOUNT CHECK#1 ECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC]DN <br /> INFO REMITTED <br /> ! D S� 00 <br />