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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTHSERVICFS ENVIRONMENTAL HEALTH DIVISION r- <br /> Ng I-WEBER AVE.30 FLOOR.STOCKTON.CA 95M (209)468-3420 C <br /> D!QN-REUMAULLPERMI EAPIRES 1 YEAR YROW DATE ISSUED <br /> CII'Y/ZfP✓JCAL��`] U r I `''�,..J(� PA/RC�ELL SIZF/APN_ <br /> OWNER NAME&' /ADDRESS �'T` <br /> CffY/ZIP_ �3l UC�fK-J1`27Y1 ��.=C.,.Zf TPHONEa,/ <br /> CONTRACTOR ___ _ ADDRESS <br /> CITVRIP ^—._- — PHONE_ <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X V TOWNSHIP,RANGE,SECTION,_ <br /> PERC TESTIS)( )ROW MANY APPLICATION M: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDTTION ESTRUCTION <br /> INSTALLAITON WILL SERVE: ❑RESIDENCE ❑COMMERICIAL HER <br /> NUMB RR OF LIVING UNITS: NUMBER OF BEDROOMS:, NUMBER OF EMPLOYEES:`_ <br /> CIIARACTER OF SOIL TO A DEPT.4 OF 3 FEET: PTT/SUMP SOIL CHARACTER' _ WATER TABLE DEPI'H <br /> ❑SEPTIC TANK/GREASE TRAP TYPEIMPG CAPACITY NUMBER CF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE- <br /> (3 uEr <br /> INE❑ELFT STATION SIZE- TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM). <br /> ❑LEACHING LINE NUMBER do LENGTH OF LINES ! INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION DROPERTY LINE <br /> ❑FILTER BED WIDTH LhNGTH DEPTH <br /> DISTANCETO NEAREST:WELL FOUNDATION:_ PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE _ <br /> ❑SEEPAGE PIT'S WIDTH{ _ LENGTH _DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUIMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TONEARFST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUTN COUNTY <br /> ORDIAN 'TATE LAW I.E.S D REGULATIONS OF SAN JOAQUIN COUNTY. �L <br /> SIG ���- TTTLE (/W <br /> V <br /> �l <br /> r. <br /> ton OKpv <br /> �7 <br /> I <br /> POR DEPART ANI'IE ONLY <br /> APPLICATION ACCEPTED BY: <br /> �\ <br /> TANK,PTT,OR SUMP INSPECTCD BY: <br /> FINAL aqi,,CTLON BY: <br /> f.OMME:iTS. <br /> a <br /> T <br /> l cLr�,ve. ,j� �.rsyzr �� i� r„-��✓Yl r'Y/ f�YI.FL•-'. � .r�/i �''/ �,CL.I:/h �'3�r-/' <br /> PF.CODE SC AMOUNT I RI>rElt'COBY DATE 11T SEPTIC ILIO <br /> INFO REMTTTEU CASH( <br /> O-U 0 r 1 a L41 o k— --�q Z-3 fn 4 C, . a�c�s� O-P pa n-}-tmI <br />