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LIQUID WASTE PERI '
<br /> } J 70AQU]N COUNTY PU$LIC HEALTH SERVICES ENVIRONM4 �-L HEALTH DIVISION
<br /> 344 E.WEBER AVE S"°FLOOR,STOCKTON,CA 95202(209)`469-3420 I,.i' "",' :.
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<br /> �� ON,-RJEFUNDABLGF. MIT EXPIRES 5 QES �ASSUED
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<br /> ,JOB ADDRESS /TJ�(f—L��/�� J�� PARCEL SIZE:
<br /> CITY/ZIP � BUILDING PERMIT N
<br /> F OWNER NAME �� �l v ADDRESS
<br /> CiTYlZIP - - PHONE NUMBER
<br /> CONTRACTOR G ADDRESS
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<br /> ClTYIZIPr�f � ���� PHONE NUMBER
<br /> GEOGRAPHICAL INFORMATION: COORDINATES: X Y TOWNSHIP RANGE SECTION
<br /> { TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: l l
<br /> NEW INSTALLATION RESIDENCE NUMBER OF BEDROOMS: Y
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<br /> REPAIR/ADDITION U COMMERCIAL
<br /> fr ❑ DESTRUCTION ❑ OTHER NUMBER OF EMPLOYEES:
<br /> f ❑ ENGINEERED/ALTERNATIVE
<br /> CHARACTER OF SOIL TO DEPTH OF 3': PITISUMP SOIL CHARACTER: WATER TABLE DEPTH:
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<br /> ❑ PERC TEST(S) HOW MANY /APPLICATION#
<br /> SEPTIC TANK TYPE/MFG_ �� CAPACITY 2_6 0 #OFCOMPARTMENTS
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<br /> q ❑ GREASE TRAP TYPE/MFG CAPACITY #OF COMPARTMENTS
<br /> 1 ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE I
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<br /> ❑ LIFT STATION SIZE TYPE OF PUMP SANDOIL SEPARATOR(ENCLOSED SYSTEM) I
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<br /> EACH LINE OF LINESLENGTH OF LINESDISTANCE ro NEAREST; wELi�� .,FOUNDATION 20 PROPERTY LINE__, L�_
<br /> INFLITRATOR CHAMBERS:
<br /> ❑ FILTER BED WIDTH LENGTH DEPTH DISTANCE TONEARW!": WELL FOUNDATION PROPERTY LINE
<br /> ❑ - MOUNDED WIDTH LENGTH DEPTH DISTANCE TONEARESf: WELL FOUNDATION PROPERTY LINE '
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<br /> ❑ SUMPS WIDTH LENGTH DEPTH- DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH - DISTANCETONEARE.ST: WELL- FOUNDATION PROPERTY LINE
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<br /> SEEPAGE PITS # DIAMETER . DEPTH DIC'fANCETONEAREST: WELL - FOUNDATION /Q PROPERTY LINE j�
<br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS
<br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY.
<br /> [N1MUM 24 HO ADV NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)468-3423
<br /> SIGNED: TITLE: DATE:
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<br /> I DF.PARTMENT USfE ONLY
<br /> APPLICATION ACCEPTE BY: DATE:� IQ. Z�Z AREA EMPLOYEE IDR DIST LOCATION
<br /> C INSPECTED BY: D TE�' I-v?— PERMIT FINA L1 YES DATE: ��-0Z INSPECTOR: 'j
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<br /> COMMENTSvu
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<br /> PE CODE SC INFO. AMOUNT CHECK#! ASH RECEIVED DATE PERMITI5ERVICE REOUESTR, _ INVOICE# SEPTIC IDR .j
<br /> REMITTED BY
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<br /> 2(1 4,705'
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<br /> 1 REVISED 9-15 1
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