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LIQUID WASTE PERMIT- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3R°FLOOR.STOCKTON,CA 95202 (204)468-7420 <br /> p� NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> rJOBADDRESS �✓ j�CJ (J J <br /> k+ CITYYLIP C7Ci 7 �.�"T r� PARCEL SIZFJAPN � <br /> OWNER NAME1JC�udAI ;<"Z�-/moi ADDRESS <br /> CITYMP - PHONE 4_77--Z <br /> CONTRACTOR- ADDRESS <br /> 5 CTTYfZIP .EaY7"�!F/ t-i`2�11+� __._PHONE � <br /> GEOGRAPHICAL INFORMATION:COORDIANTES- X Y TOWNSHlP_RANGE_SECPION <br /> PERC TEST(S){ )HOW MANY APPLICATION A: <br /> TYPEOFSEPTICWORK: ❑ NEWINSTALLATION EPAIRIADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> Itk NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS-- NUMBER OF EMPLOYEES:- <br /> 4 <br /> MPLOYEES:_Y <br /> CHARACTER OF SOILTO A DEPTH OF 3 FEET: P]TfSUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTfC TANKIGREASE TRAP TYPFJMFG CAPACITY NUMBER OFCOMPARTMENTS <br /> { ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE- <br /> 11 LIFT <br /> INE❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> f <br /> LEACHING LINE NUMBER&LENGTH OF LINES_ _! INFILTRATOR CHAMBERS <br /> " DISTANCE TO NEAREST: WELL � FOUNDATION �/�� PROPERTY LINE <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 /> J <br /> DFSTANCE.TO NEAREST: WELL lZl l_ FOUNDATION PROPERTY LINE <br /> 1i ❑SUNIPS WIDTH LENGTH DEPTH <br /> ! DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> i <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERT! HAT I HAVE PREPARED T 15 APPLICATION AND THE R'ORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES, B LAWS,AND R AND GULATIONS OF SAN JOAQUIN COUNTY. }��A1 _ <br /> ({ - SIGNED:,/ r^� TITLE:4 a L✓ DATE: C- <br /> I � <br /> fk <br /> r 666 � 1 <br /> i <br /> e <br /> f <br /> � F{,iR DEP hfi'USE ONLY <br /> APPL1CATlON ACCEPTED BY: (- I) ✓lds_JfL 1 �, f! <br /> C �� bATE: f 4 II <br /> TANK, IT OR SUMP INSPECTED H Y: DATE: W <br /> FINAL INSPECTION BY'. <br /> COMMENTS: <br /> ? PEC'ODE SC AMOUNT HECK RECEIVED RY DATE PERMIT/SERVICE REQUEST M SEPTIC IDN <br /> 1 INFO REMITTED CASH <br />