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LIQUID WASTE PERMITT <br /> SAN JOAQi N COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL t.-ALTH DIV,I5O <br /> Ap p ry g.,.�q,�. R <br /> 304`E.WEBER AVE.,3 FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> e .. <br /> CNON-REFUNDAB E PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ,[ 'yy� <br /> JOB ADDRESS m�� 'J wS <br /> //�'� ] s <br /> CITYIZIP E'��kL 1t1 PARCELSIZEIAPNLIS 4 <br /> OWNER NAME cS 1 ro A 5fQtkfD^Vk DDRES S a I to (0. <br /> CITYMP y PHONE ,�ya,�' [ ��rti�Y�JXn / f/►��fil <br /> CONTRACTOR Anckv 'tl^� ADD RFSS�Lbos Y 1 bn CPA I f 4,-L. 14D <br /> CITYIZIP .)_ E,./ PHONE �- <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP RANGE SECTION <br /> 60 <br /> PERC TEST(S) "�HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPEIMFG CAPACITY NUMBER OF COMPARTMENTS <br /> Cl 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 ! INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST; WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO.NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> 17 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 /> ❑SUIVIPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 13 DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY C TIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIA AT AWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. r fq <br /> SIGNS TITLE:(�I/f \�{c�� DATE: <br /> �Vr <br /> % <br /> V <br /> v f <br /> e <br /> h <br /> SA N JOAC U'tJGO N Y <br /> r P I WAIT nmRinll IS <br />^•'•°'`w'�9q.� `f'«,ate ,��,,.^+�.��_- _ FOR DEPaWMENT USE ONLY ..... I y <br /> APPLICATION ACCEPTED BY: - DATE: <br /> TANK,PIT OR SUMP INSPECTED BY: SATE: <br /> � r, <br /> 49WN BY: � �L�! `fes <br /> COMMENTS: ��1�� � �� •.J . ' <br /> PE CODE SC AMOUNT C ! RECEIVED BY DATE., - PERMMSERVICE REQUEST# SEPTIC ID# <br /> INFO REM=D ==tASH <br />