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LIQUID WASTE PERMIT '%%R <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �.. <br /> Fp •�'yA'�lc 304E.WEBER AVE.,3RD FLOOR.STOCKTON,CA 95202 (209)468-3420 <br /> 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED R e 1 EC E S-�-E� <br /> JOB ADDRESS Z57fa LA M k -f-Pab-A ]ZO, IS S 1 o-ly y1M1OTGJI.. <br /> CITYMP S�'oz.K-�o-+..J PARCELSIZF/APN ZO 01C C-"- �NSP��i�N'yN <br /> OWNERNAME_ I'"1ryD� 9�✓�'V ADDRESS ppyy pp,, <br /> CITYMP y PHONE L66 Z'D7+�YJ <br /> CONTRACTOR Mf.�Q'NrT�.n stio PST T•E.IC. ADDRESS 5050 E . MOeA245 RA, <br /> CITY/ZIP LOFT=1 cA QSZL40 PHONE 7 Q'ZSSZ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SEC`nON <br /> PERC TESTIS) ( ) HOW MANY APPLICATION B: <br /> TYPE OF SEPTIC WORK: , ❑ NEW INSTALLATION P1, REPAIRIADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE . ''kCOMMERICIAL ❑OTHER <br /> ,,'' 11 <br /> NUMBER OF LIVING UNITS: NUMIiFF ,, t <br /> EROFBFDROOMS:� NUMBER OF EMPLOYEES:_ <br /> CHARACTER OFSOILTO A DEPTH OF3 FEET: PIT/SUMP SOIL CHARACTER: LOf VV% WATER TABLE DEPTH_ <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑JJ LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> W"CHING LINE NUMBER&LENGTH OF LINES 7-- / loo/ INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL 1'500+FOUNDATION �04 PROPERTYLINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED *IDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> XSEEPAGE PITS WIDTH 310"' h&4ff M•l Z DEPTH 2-5 J <br /> DISTANCE TO NEAREST: WELL SD•r FOUNDATION Zo ' PROPERTY LINE 2a / <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCFS_�L/T�_LAWNS,ANDDRRULES AND REGULATIONS OF SAN JOAQUIN COUNTY. ^ ��s <br /> SIGNED:__ WN UJ Ii�Cr'R�T' TITLE: �^�` FV �- DATE:�b d 0O <br /> 1 <br /> Tj <br /> t_t�ff r6 <br /> 1 <br /> l + <br /> I <br /> 6 <br /> r <br /> C <br /> ti h <br /> FO EPARTMRNT USE ONLY PUBLH;;;;,,,;.TH SER VICES <br /> APPLICATION ACCEPTED BY: <br /> ENVIRONMI-nLil.HEAT 7H DI <br /> VIEjw <br /> TANK.PIT,OR SUMP INSPECT ❑ DATE: <br /> i <br /> FINAL INSPECTION BY <br /> COMMENTS: <br /> PECODE SC ppAMOUNI' HECKM RECEIVEDBY DATE PERMIT/SERVICE REQUEST It SEPTIC TDM <br /> INFO Mtr-MT_n <br /> 2S' �'I V3 00 o z <br /> so - <br />