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f . <br /> LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3R°FLOOR,STOCKTON,CA 95202 , '(209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED �...s,,.••.s <br /> JOB ADDRESS rE t:> _ <br /> CITY/'ZIP PARCEL SIZFJAPN <br /> OWNER NAME A u 26 B ADDRESS _. <br /> CITY/ZIP PHONE <br /> I �c� > 1 r �• ADDRESS <br /> CONTRACTOR r <br /> CITYIZIP 1 S.Z I PHONE - c%� 3/ •�'4r 1 r G <br /> w <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE--SECTION 6 <br /> PERC TEST(S) ( ) HOW MANY APPLICATION p: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION 2--'REPAIR/ADDITION C1 DESTRUCTION <br /> INSTALLATION WILL SERVE: [3 RESIDENCE 2<06MIMERICIAL ❑OTHER <br /> 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 /> i IR'SEFTIC TANKIGREASE TRAP TYPFJMFG ._ CAPACITY :9000 —NUMBER OF COMPARTMENTS_ 1 ._ <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL12Q,r FOUNDATION PROPERTY LINE <br /> GKFT STATION SIZE'/10 &P TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES ) INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL�dO FOONDATION DROP£RTY LINE <br /> arfILTER BED WIDTH , LENGTH�/a0• DEPTH_!t2p— <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TONEAREST: WELL FOUNDATION PROPERTY LINE <br /> 0 SEEPAGE PITS 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 NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE W ITH SAN JOAQUIN COUNTY <br /> ORDIANCES,S AT LAWS,AND RULES D REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1 SIGNED• <br /> ` Qt TITLE:_ DATE: <br /> a <br /> - c <br /> t <br /> t <br /> z <br /> P <br /> e <br /> z V T <br /> Ft ;' 0 <br /> Ap IN RCE <br />