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i " LIQUID WASTE PERMIT ��// o-A R <br /> . . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HI?7CLTH DIVISI( <br /> 304E.WEBER AVE.,3P"FLOOR,STOCKTON,CA 95202 (2(M))468-1420 FREC?I. ES-rE <br /> NON-REFUNDABLE.PERMIT EXPIRES I YEAR FROM DATE ISSUED Fc--) , /kt_L <br /> JOB ADDRESS yZ-4(e rC.(/ 1C [) -CA Rc,,+P INS�I��t�N <br /> CITY/ZIP � <br /> �J PARCEL SIZE/APN <br /> OWNER NAME /JJ 4S N�j 7,/1 F-�' t/'C/I//G ADDRESS <br /> CITY/ZIP PHONE _ <br /> CONTRACTOR t L'-EP, ADDRESS Q /1._ S <br /> CITYrzi _ f'J2N /C'-"� PHONE�7 S __3 /.Z�2_ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP RANGE SECTION <br /> PERCTEST(S) ( ) HOWMANY APPLICATION R: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE IgCOMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS:— NUMBER OF EMPLOYEES:— <br /> CHARACTER OFSOIL TO A DEPTH OF 3 FEET: �// PIT/SUMP SOIL CHARACTER: H/AV WATER TABLE DEPTH_ <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY__NUMBER OF COMPARTMENTS <br /> ��� <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELLT FOUNDATION PROPERTY LINE <br /> ❑LIFI'S'I'Al'ION SIZE I'YI'EOFPUMP SAND OIL SEPARATOR(ENCLOSED SYS'I'END <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NQQE�,A��RJ�ESST: WELL FOUNDATION P PERT INE <br /> FILTER BED WIDTH , 7 LENGTH 1/S—T DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE-PAMENT <br /> 13 SEEPAGE PITS WIDTH LENGTH DEPTH RECEIVED <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH AUG - 1 2000 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH SAN JOAQUIN COUNT) <br /> PUBLIC HEALTH SERVICES <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY CTNE'ENMENTAL HEALTH DMSIU; <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SANJOAQUIN COUNTY <br /> ORDIANCES,STATE LAW',AVDXULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: � � TITLE: DATE — � <br /> i <br /> r <br /> V <br /> fill <br /> FT <br /> S <br /> FOBR I EPA`RTMVNT E ONLI' cru 1 1 <br /> APPLICADED <br /> ONACCEPTBY: v G �' ` WII�"J \ DATE, w <br /> TANK,PILORSUMPINSPf: DATE <br /> FINAL INSPECTION BY: �� j <br /> COMMENTS: oV y 1--r <br /> =--IL— <br /> PECO SC AMOUNT HECK It/ RECEIVED BY I DATE PERMIT/SERVICE REQUEST♦ SEPTIC IDN <br /> IMV RBMTTT CASH <br /> Zl St20Q�'�. <br />