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t �n n' LIQUID WASTE PERMITn , CYTI <br /> ham' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTHI� U -TEEC <br /> 304 E.WEBER AVE.,3R9 FLOOR,STOCKTON,CA 95202 (209)468-3420 F=C)Fl .^L-1- <br /> -REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSURIJ S P 1E <br /> JOB ADD Su <br /> CITYMP PARCEL SIZFJAPN <br /> OWNER -AME ADDRESS <br /> CITYIZIP �• PHONE !r <br /> CONTR R ADDRESS i <br /> CITY/zl PHONE <br /> 466 <br /> I , <br /> I GEOGRAPHICAL;INFORMATION: COORDIANTES: X Y TOWNSHIP RANGE SF.0 ION <br /> PERC TEST(S) (: ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION yl REPAIRIADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:--JG NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: ,*�► J PIT/SUMP SOIL CHARACTER: WATER TAB DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFC3::j4j..._V� CAPACITY EA NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE C <br /> ©LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> D <br /> LEACHING LINE NUMBER&LENGTH OF LINES Y_�1 0 INFILTRATOR CHAMBERS <br /> l/ <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> F DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> + ❑MOUNDED WIDTH LENGTH DEPTH <br /> It DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ' `C�SEEPAGE-PITS WIDTH LENGTH DEPTH � <br /> Ion. <br /> ! F <br /> ' DISTANCE TO NEAREST: WELL 1 l�A J11. FOUNDATION PROPERTY L[N <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> r DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> f + I HERE FY TI{A I AVE PREPARED THIS APPLICATION AND THE WORK WILL BE DO IN CCORDANCE WITH SAN JOAQUIN COUNTY <br />{ <br /> ORD CE , A GULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: _ TITL &-Moto <br /> DAT • r <br /> f <br /> Z4 7 4� <br /> lit' -� <br /> . - ter <br />