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/ :7 ,L L- <br /> LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY M'BUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E WEBER AVE..JAO FLOOR.STOCKTON,CA 95202 l2891468-342-0 - <br /> lAN 0 2 2001 'SON REFUND\BI F PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ,oBaAPRESs_ r...CTrCS r= L.- e <br /> , <br /> CTTCI �;�:. ,�C' J ELL SIZE/APNir, '} l <br /> ADDRESS (! L}�•-� �l" /F�n SrO `I <br /> OWNERNAME�)� /—/---ry <br /> CITY/7JP W /6"�l LCL{ S �( •./ PHONE `"I 6 P'J 36JIT 7'1 <br /> CONTRACTOR ADDRESS <br /> CffYlLIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTFS: X Y TOWNSHIP_RANGE_SECTTON_ <br /> FERC TESTIS) ( ) HOW MANY APPLICATION k: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION <br /> INSTALLATION WILL SERVE: C3 RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES:_ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: <br /> PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH__ <br /> ❑SEPTIC TANK/GREASE TRAP TYPEIMFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE-- <br /> [3 LIFT <br /> INE _❑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 /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSALPONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> — <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLI ON AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> IANCES,ST N OF SAN JOAQUIN COUNTY. <br /> 1p"D <br /> TITLE: DATE-- <br /> SIGNED: <br /> ATESIGNED: <br />