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LIQUID WASTE PEP" IT
<br /> Cl JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROr ITAL HEALTH DIVISION
<br /> 304 E.WEBER AVE 31°FLOOR,STOCKTON,CA 95202(209)469-3420
<br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FILE COP.
<br /> JOB ADDRESSd "_ T/]y*7z& APN 6-7072(a^ PARCELS IZE:��
<br /> CITYIZIP . /`�"i!i BUILDING PERMIT k (,d 0 5 2—
<br /> OWNERNAME C��Qr�� ADDRESS - ~
<br /> CITY/ZIP - - PHONE NUMBER - 69 ✓ ^' f/�
<br /> CONTRACTOR ADDRESS
<br /> CITYIZIP tlJ �jPHONE NUMBK.1 Is 9 1
<br /> GEOGRAPHICAL INFORMATION: COORDINATES: X Y LLL TOWNSHIP RANGE SECTION
<br /> TYPEOF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: 7�—
<br /> e-NEW INSTALLATION !%9 RESIDENCE NUMBER OF BEDROOMS:
<br /> ❑ REPAIR/ADDITION ❑ COMMERCIAL
<br /> NUMBER OF EMPLOYEES:
<br /> ❑ DESTRUCTION C7 OTHER
<br /> ❑ ENGINEER ED/ALTERNATIVE
<br /> CHARACTER OF SOIL TO DEPTH OF 3': PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH:
<br /> ❑ PE CTEST(S) HOW MANY APPLICATION# d
<br /> SEPTIC TANK TYPE/MFG_ � CAPACITY / I©0 #OF COMPARTMENTS
<br /> ❑ GREASE TRAP TYPHIMFG CAPACITY #OF COMPARTMENTS
<br /> I
<br /> ❑ -PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> ❑ LIFTSTATION SIZE TYPEOFPUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM)
<br /> #OF LINES: LENGTH OF LINES:
<br /> LEACH LINE DISTANCE TO NEAREST: WELL/;!?!" FOUNDATION PROPERTY.LINE l
<br /> INFLITRATOR CHAMBERS:
<br /> ❑ FILTER BED -WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCE TONEARE.ST: WELL FOUNDATION PROPERTY LINE
<br /> ❑ SUMPS WIDTH LENGTH DEPTH DISTANCETONEARIl WELL FOUNDATION PROPERTY LINE '
<br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCE TONPANEST: WELL FOUNDATION PROPERTY LME - J
<br /> ❑ SEEPAGE PITS # DIAMETER DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> I HEREBY CERTIFY THAT 1 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 /> ]MUM 24 U A N E ICE REQUIRED FOR INSPECTIONS-PL/EASE ALL(209)468-3423 //��
<br /> SIGNED TITLE: 'iL O � I. DATE/;Z 6 �O
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<br /> DF,PARTMENT USF NL.Y
<br /> ANPLICA'fIONAl'CEPTEb / �- - - - - - �- DATE: .?� REA 2-1-- -.EMPLO'{EE_ID#_!_�//DSST.RIC�LDc_7 L4CA710N�
<br /> INSPECTED BY: DATE: O Q PERMIT FINALAU YES DATE: INSPECTOR: '
<br /> COMMENTS:
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<br /> PE CODE SC INFOAMOUNT CHECK#1C SH RECEIVED DATE PERM ITISERVICE.REQUEST# INVOICE# SEPTIC ID#
<br /> REMiTfED BY
<br /> 2� I117 32b- . 1�-52s
<br /> REVISED 9-1541
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