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T <br /> LIQUID WASTE PERMIZ <br /> w �SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTACREALTH DIVISION t ` <br /> 304 F.WEBER AVE.,3R0 FLOOR,STOCKTON,CA 95202 (209)468-3420 d ", <br /> !! <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE.ISSUED ' <br /> JOB ADDRESS , iI e <br /> e 4 <br /> CITY2IP PARCELSIZIJAPN <br /> OWNER NAME —,jj 6 -:k ADDRESSII" ` -. <br /> CITY/ZIP_ 1 fl PHONE._ { 054, !-71 <br /> CONTRACTOR LL)ALJ {� ADDRESS J . z—) x—)*v-c Gf <br /> CITY2lP `L PHONE I 3 lO 7 I f <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGESECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: Cl NEW INSTALLATION Cl REPAIRIADDITIONf 'DF STRUCT[ON <br /> INSTALLATION WILL SERVE: 13 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 TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I <br /> ❑LEFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1 <br /> ❑LEACHING LINE NUMBER&LFNGTH OF LINES ! INFILTRATOR C14AMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> Cl FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> I <br /> ❑MOUNDED WIDTH LENGTH DEPTH I <br /> I <br /> DISTANCETO NEARTrST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENG'T'H DEPTH a <br /> 4 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE M <br /> i <br /> 1 HEREBYY AT I HAVE PREPARED TtM APPLICATION AND THE WORK WILT.BE DONE IN ACCORDANCE WITH SANJOAQUIIN COUNTY <br /> ORDIANC S,STATE AWS,AND RULES A IONS OF SAN JOAQUIN COUNTY. <br /> SfGN£D: TFTLE: �!/�� --DATE: 45 <br /> —22 <br /> I <br /> 1 <br /> � f• <br /> i <br /> SF N AD <br /> _NV HOT IMF:TF .HE,AE: 4-I;I <br /> S P. �— <br /> n <br /> 5 ��t <br /> T' S <br /> s <br /> A. <br /> We <br /> FU IF: k I•MENT USF:ONLY <br /> AI'PLICATIONACCEE'TL"DBY: - v` C, (.,�"�L J DATE! 'C./"-' c "= <br /> TANK,Try"I'.OR SUMP INSPEC`;-E BY' DATE:- i <br /> HNAI_INSPEC['ION <br /> COMMENTS: <br /> PECODE SC AMOUNT CHECK N! RECEIVED I3Y DATE PERMITISER V ICE REQUEST# SEP'T'IC IDN <br /> INFO R'EM E <br /> �t Yt'- <br />