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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E.WEBER AVE..3R0 FLOOR,STOCKTON.CA 95202 (201)465-3620 <br /> NUN.REFUNDABLE.PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP PARCEL SIZEJAPN <br /> OWNERNAME ADDRESS <br /> CITYIZIP PHONE <br /> CONTRACTOR ADDRESS - <br /> CITYZP - PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <br /> PERCTFST(S) ( ) HOW MANY APPLICATION Ie: <br /> TYPE OF SEPTIC WORK: ,Q" NEW INSTALLATION ❑ REPAHUADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL _IT TTHER <br /> NUMBER OF LIVING UNITS: 1' NUMBER OF BEDROOMS--�� NUMBER OF EMPLOYEFS: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH_ _ <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY - NUMBEROFCOMPARTMENIS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL'- FOUNDATION PROPERTYLINE <br /> ❑LIFT STATION SIZE TYPEOFPUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE- <br /> 0 1 IUIERBED <br /> INE❑1ILTERBED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL_ � FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH - PAYMEN I <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERT4&WE E�� <br /> ❑SUMP5 WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION Q <br /> PROPER tiftyE' V <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH SAN JOAQUIN COUNTY <br /> DISTANCE TO NEAREST. WELL FOUNDATION PROPFJ�Ti I kEALTH SERVICES <br /> .�iEAcT.rmVISION <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDWNCMS,STATE LAW$AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: TITLE:_ DATE: <br /> - - -----------#-- ---------- - ----- <br /> - --------------- <br /> 1 <br /> t r <br /> i <br /> a <br />