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LIQUID WASTE PERMIT '- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION . <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 R. ;..' _ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S L d /y 4 <br /> CITYfZIP PARCEL SIZEIAPN 0077- <br /> ,,,�!! v <br /> #, ' D (. I <br /> r oft <br /> OWNER NAME ` VL�� �j lT 1/1 YI lw_,� ADDRESS { Y <br /> CITY/ZIP <br /> PHONE aoct IL .. 0�_ <br /> CONTRACTOR 'S ( ADDRESS <br /> CITYIZIP L d f 06 `�ja <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP RANGE_SECTION <br /> FERC TBST(S) ( ) HOW MANY I APPLICATION#: <br /> TYPE OF SEPTIC WORK: Cl NEW INSTALLATION ❑ REPAIRIADDITION ❑ 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: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANKIGREASE TRAP TYPEIMFG CAPACITY NUMBER OF COMPARTMENTS f <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE-- <br /> • <br /> INE -❑LIFT STATION SIZE TYPEOF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES 1 INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL FOUNDATION: PROPERTY LINE I <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE--p.dyn q LN„f <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH RECEIVED <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ISI Q �j <br /> ❑SUMPS WIDTH LENGTH DEPTH NQ`!V �+ L000 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> __84*ft)A_QUID4 CGUiVTI' <br /> PUBLIC HEALT❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> ENMONMFNTAi HFAr nivI SI()'j <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, TE L WS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ��'-rr��qY]�/ I <br /> 1!5l /�� <br /> SIGNED: TITLE: [JGI.]/ DATE: <br /> Ll <br /> • i <br /> 13T wil <br /> 1 <br /> e <br /> 0 <br /> 1 o - <br /> FT <br /> t <br /> f i <br /> Ilud Vdl Ij <br /> r.. ICOR DEPARTMENT USE ONLY �Xy�fJ/l/ J4 <br /> I <br /> APPLICATION ACCEPTED BY: DATE: I/ tJ L/i1 7 J <br /> TANK,PIT,DR SUMP INSPECTED BY: PATE: <br /> �aej <br /> FINAL INSPECTION BY: <br /> COMMENTS: / <br /> PECODE SC AMOUNT CHECIjp RECEIVED BY AT PERMTTISERVICE REQUEST# SEPTIC ID# <br />• INFO REMITTED <br />