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LIQUID WASTE PERMIT _ o / cls' <br /> SAN JOAQOIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION {j <br /> 304 E.WEBER AVE.,3R11 FLOOR,STOCKTON,CA 95202 (209)468-342f) p Il <br /> /IVON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE Y; I 1 i "'1---5 <br /> r <br /> JOB ADDRESS _ r <br /> CITY/ZIP <br /> PARCEL SIZEJAPN -r <br /> OWNER NAME ADDRESS <br /> CITY/ZIP /PHONE <br /> CONTRACTOR t ns <br /> ds ADDRESS <br /> d A <br /> CITY2IP J PHONE�O 4 6 7 <br /> I <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGE_SECTION <br /> PERC TEST(S) ( )) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: !] NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION f <br /> INSTALLATION WILL SERVE: A'R-'ESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: f 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 /> ❑SEPTIC TANK/GREASE TRAP TYPEIMFG_cb�9.P�.+�" ,„,- CAPACITY ,D NUMBER OF COMPARTMENT�B .�" <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE{ III <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES I INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL /30 0FOUN_DATION 1 0 r PROPERTY LINE 1 A ' <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY-LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUI43PS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> E3 DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPAREYTHIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. 4 <br /> SIGNED: TITLE;_ DATE: <br /> i <br /> ni 141 <br /> UIP <br /> W <br /> l <br /> A SD fl QlN OU <br /> PU <br /> V <br /> a <br /> - . <br /> `� ,c.�T SSE GirL"k'-` <br /> APPLICA'T'ION ACCEPTED BY; <br /> TANK,PIT,OR SUMP INSPE _ <br /> � <br /> ATE:y <br /> �- <br /> 'FINAL INSPECTION BY: <br /> IF <br /> COMMENTS: <br /> PECODE SC AMOUNT RECEIVED BY DATE PERMIT/SERVICEREQUEST# SEPTICIDO { <br /> INFO R-M TTED 1CASH - - <br /> zr &ooa7 p 2 <br /> 2 <br />