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_i <br /> LIQUID WASTE PERMI <br /> SAN JOAQi,4N COUNTY PUBLIC HEALTH SERVICES ENVIRONMFNTAL IJALTH DIV i O , ,„; - -•*k,---,.V <br /> 304'E.WEBER AVE.,3 FLOOR,STOCKTON,CA 95202 (209)468-342(Y-1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � y <br />'i JOB ADDRESS ► S , rnnv6�'e�jx 'c. westo <br /> CITY/ZIP 8 ��t (,- PARC`E(L�SIrZEIA61 <br /> PN jAV <br /> �j <br /> F OWNER NAME I l9 y �°.DDRESS_ I ` ` W. <br /> ` ��`' <br /> Af' <br /> CITYPHONE <br /> IZJP <br /> 1 CONTRACTOR I , CY ADDRESS bV ` Vl <br /> CITY/ZIP �vl r PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <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: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/OREASE TRAP TYPEIMFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> - <br /> 11 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 FOUNDAT_ION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> j DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> i <br /> El 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 /> I ❑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, �,�y� ,q �+ <br /> SIGNE TITLE:I/�V(ul Is` DATE: `� L!'� <br /> U <br /> TA <br /> ull <br /> v <br /> e <br /> G <br /> K <br /> 5 N JDAC UIN CO Nl Y <br /> �r R L a <br /> FOR DKPaRMENTUSE ONLY _ <br /> APPLICATION ACCEPTED BY: w L- ATE: - <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE <br /> F�N BY: I ✓LSV ,6�-R .! <br /> COMMENTS: a=r • y /r <br /> PE CODE . Sc AMOUNTC I RECEIVED BY DATE. PERMTT/SERVICE REQUEST# _ ,SEPTIC ID# <br /> INFO REM ASH <br /> C6 <br />