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LIQUID WASTE PERMIT `w'3 Ls 'wryx <br /> f SAN JOAQL'IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DSY'ISIC? <br /> ;USE WEBER A%E.,3"FLOOR.STOCKTON.CA 95,02 (?091565.3530 - <br /> 1 <br /> N'ON'REFUNDAR E PERMIT EYPlIR S 1 'E.RyFROM DA ISSUED F <br /> JOB ADDRESS ✓— Y/ r I�t L c . <br /> CITYMP PA RCEL SIZF/APN <br /> OWNER"' <br /> ADDRESS <br /> � _qd - <br /> CITYlZ[P PHONE ,J <br /> CONTRACTOR -11 ADDRESS <br /> CITY2IP +� _ PHONE_ L _ <br /> Fi' <br /> GEOGRAPHICALINFOR\IATTON. COORDIANTES: X YTOWNSHIP_RANGE_SECTTC)N P£RC TE5T(S)( ) HOWMANY APPLICATfON M: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION' <br /> F INSTALLATION WILL SERVE: Q RESIDENCE ❑COMN[ERICIAL IJ OTHER <br /> i NUMBER OF LIVING,UNITS: NUMBER OF HEDROOIS: NUMBER OF EMPLOYEES <br /> i CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUSIP SOIL CHARACTER: WATER TABLE DEPTH_ <br /> ❑SEPTIC TANK;GREAST TRAP TYPUMFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO N EAREST: WELL FOUNDATION PROPERTY LIVE _ <br /> f ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR I FNCLOS ED SYSTEM) <br /> ❑LEACHINC LINE NUMBER&LENGTH OF LINES f INFILTRATOR CHAMBERS L! - <br /> 1 DISTANCE TO NEAREST: WELL FOU\DATION oROPERTY iTNE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> !! DISTANCE,TO NEAREST: WELL FOUNDATION PROPERTY'LINE' <br /> r <br /> F <br /> MOUNDED WIDTH LENGTH DEPTH 1AIN'P <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LlIz - <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST, WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> Fr DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCETONEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUI\'COUNTY <br /> ORDI:INCES,STATE LAWS,AND RULES AND REGULATIONS OR SAN JO AQUIN COUNTS'. <br /> SIGNED: TITLE:_ DATE: <br /> I <br /> i i ii cll ii ! ill EE <br /> ! ! ill I I IIE I II I <br /> f I II IE <br /> I � ! ! I I I II II ' 111 ! f ! II 1 <br /> I I ! ! E I l I I <br /> 1 114 j I <br /> iE <br /> ill 11 li , I 1 I I fl <br /> Will <br /> I I ! I I 1 3 ! I <br /> I <br /> 1 I I III I { llli l ii I ! 111i <br /> i 4 li � IIIIII � IIII � I I 1111 ! ! 11 <br /> FOR DEPARTMENT USE ONLI A< <br /> y <br /> APPLICATIOW ACCEPTED B Y: DATE. <br /> TANK,PIT.ORSL:.IP!`'SPECT I DATE: <br /> F[.1'iL INSPEC710.'. a 11 0� <br /> COMMENTS-�' ~Y 4 &-A k r <br /> PECOOE I SC AKIOUSNT CHECKRECEICED Bk- DATE PER.NIIY/SER�ICE REQUESTe SEYrlc sn• <br /> t INFO RCNU7CED !_ASR <br /> / o[q �7 <br /> b �k n+fit _v <br /> f <br />