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ti . <br /> +- LIQUID WASTE IT <br /> SAN JOAQUIN COUNTY PUBuC HEALTH SERVICES ENVIRONMENTAL IEALTH DnTSIOIx? - H FJ N 0-Tl J <br /> 344 E wEEER AVE,3R0 FLOOR.STOCKTON,CA 45202 ('B9)469-3420 <br /> NON-REFUNDABL.PERMIT EXPIRdl YEAR MQM�DATE ISSUED F- �-� ALA— <br /> JOB <br /> L LJOB ADORE5 '�••ff�'� <br /> CITYfZIP_LiA, MA ..,_ PARCEL SVPIAPN._GSg'e7�`���+ Z <br /> OWNER NAME ..v+ 3 ,NADDRESS_�." ��j�.y,1,.1 {4i;llY T'��� <br /> CITY-P Lf, 2 <br /> Lo 11 HDN£A�C�f 7l�C��S1 <br /> co—ACTOR .__., - ADDRESS c <br /> r -L7�t 'ALT_ Z <br /> - CITYfZIP PHONE_I- <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP,,,—_RANGE_SECTION <br /> V PERC TESTS) "HOW MANY t f <br /> A{js APPLICATION x: <br /> TYPEOFSEIMC WORK: ❑ NEWINSTALLATION ❑ REPATWADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> L NUMBER OFLIVING I;INIT$' NUMBER OF BEDROOMS'- NUMBER OF EMPLOYEES:_ <br /> CHARACTER OF SOIL TO A DEPTH ON 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH_ <br /> ❑SF_P'TIC TANYJGREASE TRAP TYPFJMFG CAPACITY Ni]MBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> a LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCETO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST:WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ( ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I' <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK"FILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> I <br /> ORMANCE4ATATELAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. , ` <br /> SIGNED:A. - C - 7 C TITLE' v-9lXX:r11 C DATE:71 <br /> 7{ P G [ <br /> I <br /> L <br /> ECIV <br /> I — <br /> aDi -- <br /> PLI## tN�IHU giEll <br /> IUfv <br /> FOA oKPARTMEKT USE ONLY <br /> APPS]CATONACCEPTEDBY: DATE. <br /> TANK.PTT.OR SUMP INSPECIfD BY-_--- _ HATE: , <br /> FINAL INSPECTION$Y: <br /> COMMENS'S: <br /> DECODE SC AMOUNT CHECK ' RECEIVEDBY DATE PFRHMSERVICE REQUEST$ SEC IDN <br /> �f TPD <br /> NR] R MDTED Y].SN <br />