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I, <br /> LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE-.3RO FLOOR,STOCKTON,CA 95202 (209)468-U7A 24 HR N pTl C <br /> NON-RUFUNDARLEPEIRF FR DATE ISSUED REQUESTEL7 <br /> JOB ADDRFSS o2 O Kke FOR ALL_ <br /> Cn Y� rrR-- �- REEL SIZFIAPN Ga I N S P,SE�CTI C3 N <br /> OWNER NAME 1 p 5`•!�i►'1 /'C� I7Yl ADDRESS <br /> CTTYlZJP <br /> HONE <br /> CONTRACTOR 4 f S ADDRESS'�� p / <br /> j�((A�D /Y• �Il-57� <br /> CITY2IP t.l 'f U r PHONE_ ' (X(&' L 0 <br /> GEOORAPHICALINFORMATION:COORDIANTES: X Y TOWNSHIP_RANGE_SECTION,_ <br /> PERCTEST(S)( )HOWMANY APPLICATION M: _ <br /> TYPE OF SEPTIC WORK; ❑ NEW INSTALLATION ❑ REPAIR/ADDMON DESTRUCITGN <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL Q OI HER <br /> I NUMBER OF LIVING UNITS:__ NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES:_ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: _ WATER TABLE DEPTH <br /> ❑SEPTIC TANKIGREASE TRAP TYPF/MFG CAPACITY NUMBER OFCOMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST. WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LME NUMBER ALENGTH OP LINES 1 INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION _PROPERTY LINE <br /> ❑FILTER RED 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 /> 13 SEEPAGE PIIS WIDTH LENGTH DEPTH ' <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE `\ <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAR EST: WELL _ _ FOUNDATION PROPERTYLINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED. TITLE:, DAT.Tx <br /> k <br /> FOR DEPARTMENT USE ONLY 7 <br /> APPLICATION ACCEPTED BY: ATE:t <br /> TANK.PIT,OR SUMP INSPECTED Y'. �- <br /> FINAL INSPECTION IAy, <br /> COMMG:TS: - -- - <br /> PF:CODE SC ANOUNT RECEIVED BY DATB PERMD'/SERVICE REQUEST SEPTIC IDR <br /> N 0 RtT4lTTED H <br /> z2 F <br />