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i LIQUID WASTE PERMI4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAti HEALTH DIVISg4 VA c), 304 E.WEBER AVE.,3R°FLOOR,STOCKTON,CA 45262 (209)468-3420 �iS-Z 'r NON•REFUNDABLPERMIT EXPIRES I YEAR FROM DATE ISSUED C)4- � F. ^-- -- r s. JOB ADDRESS /'� �I a CITYIZIP PARCEL SIZE/APN `�� + `J OWNER NAME 'G ADDRESS d_.P< �v CITYfZIP ! 3�c7 PHONE r/D CONTRACTOR�/- ADDRESS � CITY/ZIP �` PHONE GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNS HIP_RANGE_SECTION PERC TEST(S) ( ) HOW MANY APPLICATION#: TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMNIERICIAL ❑OTHER NUMBER OF LIVING UNITS:• NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITlSUMP SOIL CHARACTER:' WATER TABLE DEPTH ❑SEPTIC TANK/GREASE TRAP TYPEJMFG CAPACITY NUMBER OF COMPARTMENTS ❑PKG TREATMENT PLANTDISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE f ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) Cl LEACHING LINE NUMBER&LENGTH OF LINES 1 INFILTRATOR CHAMBERS DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ❑FILTER BED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE ❑MOUNDED WIDTH; LENGTH DEPTH N ! DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ❑SEEPAGE PITS WIDTH 3 LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ❑SUMPS WIDTH' LENGTH DEPTH k r ' DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ❑DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE EUPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIANCES,STATE S;AN UL AND REGULATIONS OF SAN JOAQUIN COUNTY. -� �.r SIGNED. TITLE: DATE9---?- d V C U C ^,v-T i OF L L- 1 5 c JR PARTME S NLY APPLICATI0N ACCEP rFD TANK,PIT,OR SUMP INSPECTEDBY: DATE: FINAL INSPECTION BY: COMMENTS: r PE CODE SC AMOUNT CHECK# RECEIVED BY DA PERMIT/SERVICE REQUEST# SE IC IDR INFO REM