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LIQUID WASTE PERMIT [ N ��o I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL htALTH DIVISION <br /> 304 E.WEBER AVE.,3R°FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-R FUNDABLE PER T EXPIRES 1 YEAR FROM DA'Z'E ISSUED �� __ <br /> 4119 1 <br /> JOB ADDRESS C y' -y Yp <br /> PA L SIZEIAPN <br /> CITYIZIP <br /> OWNER NAME ADDRESS 17O <br /> PHONE <br /> CITY/ZIP <br /> ADDRESS <br /> CONTRACTOR <br /> CITY/ZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGE�SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑INSTALLATION REPAIRIADbITION ❑ DESTRUCTION <br /> i ❑COMMERICAL ❑OTHER <br /> ;i INSTALLATION WILL SERVE:. ESIDENCE <br /> NUMBER OF LIVING UNITS: BER OF BEDROOMS: NUMBER OF EMPLOYEES <br /> !: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY UMBER OF COMPARTMENTS <br /> ❑PKC TREATMENT PLANT DISTANCE TO NEAREST: WELL `nUNDATION� PROPERTY LINE <br /> PAYMEN i <br /> ❑LIFT STATION SIZE TYPE-OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ol RECEIVE[ <br /> 11 LEACHING LINE NUMBER&LENGTH OF LINES f_J- INFILTRATOR CHAMBERS <br /> PROPERTY Li <br /> DISTANCE TO NEAREST: WELL FOUNDATION OR- <br /> 0 <br /> ia n❑FILTER BED WIDTH LENGTH DEPTH JOAQUIN COUNTY <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY4'I"Rj4-SERVIGFS <br /> ENVIRONNIFNW HFALMH DIV151()f1 <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ki F <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH �F <br /> i r . <br /> DISTANCE TO NEAREST: WELL OUNIIATION �_ PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> i DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE O <br /> CI 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 /> ORDIANCES,STATE LAWS,ANDItYLES AND RE ATIONS OF SAN JOAQUIN COUNTY. <br /> i- SIGNED: <br /> TITLE:Te"� DATE: <br /> r <br /> 1+ <br /> 77 <br /> w <br /> k <br /> `6 <br /> i . <br /> r <br /> I ! <br /> I <br /> LL1'' I <br /> �� �-a. OR llEPARTMEN 58 ONLY <br /> APPLICATION ACCEPTED BY: L. ATE: <br /> 3 o <br /> TANK.PIT.OR SUMP iNSPE EDB DATE: <br /> 3 /20 <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PE CODE SC AMOUNT CHECK#1 RECEIVED BY DATE PERMITISERVICEREQUF.ST# SEPTIC 7D# . <br /> INFO REM I I CASH <br /> j 156,W45,1557 <br />