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LIQUID WASTE PERMIT . _ . �opr�r iojj`Qvl <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON117 <br /> MENTAL <br /> 304 <br /> DIVISION <br /> 304 E.WEBER AVE.,3NO FLOOR,STOCKTON.CA 95202 (209)468-3420 <br /> NON-REFUNDABLE{PERMIT EXPIRES I YEAR FROM DATE ISSUED - <br /> JOB ADDRESS 3 7 3 <br /> CITYlZ[P `t0`3 PARCEL SIZ:JAPN <br /> OWNER NAME Y d `S ADDRESS ` 7 W � 5 <br /> CITYI"LIP `' 1 PHONE <br /> ADDRESS aO <br /> CONTRACTOR <br /> CITYIZIP <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP----RANGE_.SECTION <br /> PERC TEST(S) { ) HOW MANY APPLICATION#; <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRlADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: <br /> PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TAN KIGREASE TRAP TYPEIMFG CAPACITY NUMBER OF COMPARTMENTS <br /> j ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES 1 INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BF.D WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION:..— PROPERTYLINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINEEIVi <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH RECDVE D <br /> 3 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH AUG 2 12001 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE SAiI.JOnC't'sr•;(;('lj;�!'{ <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH !'Ulil_I�Ff lil)il•`.%f:P'ii{ <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CE • IFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> OKDIANCE S T WS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NED: T[TLE: U DATE:_ ..._ <br /> SIG <br /> QaN <br /> 11 rAc <br /> a� f <br /> t r <br /> l r L o Gr~ r'1 ' <br /> uv{ U <br /> r <br /> w <br /> I NeLVI. <br /> i r r <br /> h ! <br /> � 4 t <br /> tLu w <br /> PT- <br /> FOR <br /> Sti <br /> USE ONLYoll <br /> yr <br /> 1 APPLICA'T'ION ACCEPTED BY:_ DATE: r <br /> -. -''TANK:PIT.OR SEI MP NSYF_CTED•[l r: W._- ----- _- - _ DA'Ri-- <br /> FINAL[NSPGCTION BY:� _"�•r�'/�.,j�`� � � - - '" <br /> COMM NTS:_, <br /> 0 <br /> PE CODE SC AMOUNT CHECI RECEIVED BY DATE PERMITISERVICE REQUEST! SEPTIC IDb•— <br /> INFO LM=D CASII <br /> 245 <br /> r <br /> d 7-jeS <br /> "Rr71 <br />