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LIQUID WASTE PERMIT��// <br /> SAN JOAN COUNTY PUBLIC HEALTH SERVICES ENVMONMENTAL ALTH DIVISION <br /> 304 E.WEBER AVE.,3P0 FLOOR,STOCKTON,CA 95202 (209)468-3420 24 HR IN®-F IIE <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED R E C�U E S-T'� <br /> JOB ADDRESS 180 /pw , "'- FC) <br /> CITYlLIP L/A111+6/1l y5 36 PARCEL SIZEIAPN 40/4c". <br /> OWNER NAME MA44 DQ IE SO44 Q I ADDRESS 4 61 I Z Al. A 44YAV <br /> S�TIvGIGTv-j '75225 PHONE CCS`?) <br /> CTIYIZIP , f _ ,l/> f/ U <br /> CONTRACTOR Df�1 ma'a'A'w ADDRESS ?0' �X• �I UO <br /> CITYMP 1-0,01, PHONE (24a`1),�,,3�y�r°�'�3 <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP-2 A//RANGE BfSECTION� <br /> PERCTe EST(S)j,�HOWMANY APPLICATION '- "2-rTYPE OF SEPTIC WORK: �❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <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: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANKIGREASE TRAP TYPE/mFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP 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 /> 0 SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH R <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE Q <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH v <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICA AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY C' <br /> ORDIANCES,ST AND RULES AND REGULATI OF SAN JOAQUIN COUNTY. <br /> S1GNE TITLE: LAV-0 '$�V"f- <br /> DATE: <br /> �h <br /> J-1 �- <br /> A E <br /> 1 <br /> IUBL III C H ALF 4 5E VIC 5 <br /> Ao <br /> 4Ii.DEPARTJZ1,N-TUSE..ONLY 1 <br /> APPLICATION ACCEPTED BY: DATE: 07QZ <br /> TANK,PIT,OR SUMP INSP D B - DATE.I7- <br /> PWAL.INSPECTION B <br /> COMMENTS: moi. / /'' 1 / <br /> PECODE Sc AMOUNT RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC[D# <br /> INF0 REMITTED <br /> S S, ps�os3 - <br /> �f <br />