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LIQUID WASTE PERMI , <br /> V ENVIRONMENTA). ,,EALTHDIVISION <br /> SANlOA�JIN COUNTY PUBLIC HEALTH SERVICES s , <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (20)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED Icy <br /> JOB ADDRESS _ <br /> CITY/Zip PARCEL SIZEIAPN <br /> 4 V a7 "°�"'- <br /> OWNER NAME ADDRESS <br /> CITYIZIP PHONE <br /> CONTRACTO ADDRESS 771.1: <br /> CITY/ZIP PHONK <br /> GEOGRAPHICAL INFORMATION: COORDIANT£S: X Y TOWNSHIP_RANGE_SECTION <br /> PERCTEST(S) ( ) HOW MANY �•' "APPLICATION.t s* <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIA-DDITION,, t": ,-`10"l,,)`DESTRUCTION a.. <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: �a PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> 13SEPTIC TANK/GREASE TRAP TYPFJMFG C��e 1. CAPACITY NUMBER OF COMPARTMENTS 2'' <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE _ . <br /> ❑LI STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING LINE NUMBER&LENGTH OF LINES 3 _10 INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL �Q& FOUNDATION� PROPERTY LINE �Q � <br /> ❑FILTERI3ED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> 0 MOUNDED WIDTH LENGTH DEPTH <br /> 77 - / DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> SEEPAGEPITSS WIDTH LENGTH DEPTH 25 <br /> 9 DISTANCE TO NEAREST: WELL FOUNDATION �rePROPERTY LINE A <br /> ❑SUNIPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY AT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STAT AND RULESVANGIIO ' OF SAN JOAQUIN COUNTY. <br /> S)`6J TITLE DATE. �� ✓- <br /> IVY <br /> IWO <br /> 1L <br /> FOR DEPARTMENT USE ONLY [� <br /> APPLICATION ACCEPTED BY: DATE <br /> TANK,PIT,OR SUMP INSPECTED B DATE: <br /> • \, <br /> FINAL INSPECTION BY: a <br /> COMMENTS: �4 <br /> PE CODE Sc AMOUNTC RECEIVED BY D TE PERMITfSERVICEREQUESTN SEPiICID# <br /> INFO REMITTED .H <br /> �sa�� a� • t�cx� <br /> OLLU �—1 <br /> kr .,nom / <br />