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LIQUID WASTE PERMIT <1 R F; t'•s o-r:c i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E.WEBER AVE.,3R0 FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-RF.FUNDABLR PERMIT EXPIRE'T YEAR FROM DATE ISSUED r j^..�(� '�E('_'l <br /> �7/�n1S <br /> JOB ADDRESS � <br /> 2 <br /> CITY/ZIP- � � D PAR/C�ELSIZFIAPN <br /> LOWNER NAME G AD/DyR ESS Ty9 lro <br /> CITYMP V�LI .CTY J I•� .t�'�/(J PHONE y•�v -/�� (J <br /> L4 CONTRACTOR ADDRESS <br /> CTTY/ZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGESECTION <br /> Ir PERC TESTIS) ( ) HOW MANY APPLICATION x: <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: 1 NUMBER OF EMPLOYEES:_ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: A PITISUMP SOIL CHARACTER: WATER TABLE DEPTH_ __ <br /> I ❑SEPTIC TANKJGREASE TRAP TYPE/MFG CONCRETE CAPACITY NUMBER OFCOMPARTMENTS�_ <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTYLINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP-SAND IL SEPARATOR(ENCLOSED SYSTEM) <br /> ` ❑LEACHING LINE NUMBER&LENGTH OF LINES J.-J qo INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH LL��'����� <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPER'IN`I,iIVr6`P4-`� <br /> ❑MOUNDED WIDTH LENGTH I_ <br /> DEPTH REC \T1.7- <br /> DISTANCE TO NEVEST: WELL FOUNDATION PROPER JJ,LINEy <br /> �EEPAGEPITS � b6w6 36 DEPTH - 251, 11 1 V f_(;T• <br /> DISTANCE TO NEAREST: WELL FOUNDATIONPR T ,UNTY <br /> ❑SUMPS WIDTH LENGTH DEPTH FWARONMENTAL HEALTH OIVI?IOL <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> r � <br /> I HEREB ER FYTHA HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY (� <br /> ORDIA ES, ATE LA ',AND LES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED. _ TITLE:_ DATE:g <br /> r <br /> cl'�p I r <br /> - <br /> ' !C <br /> L <br /> L i � <br />