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LIQUID WASTE PERI"' 7 <br /> �:`:AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV[RONMEN, ,.HEALTH DIVISION � � •" (�.-rjc. ;� �' <br /> 364 E.WEBER A-VE 31a°FLOOR,STOCKTON,CA 95202(209)468-3420 <br /> ff�� N R <br /> JOB ADDRESSFUNpABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> �Qy�` �j �` � �l f <br /> r� j / APNA � t PARCEL SIZE <br /> CITY/Zip fG <br /> BUILDING PERMIT# - <br /> OWNERNAME - - 1''+f� - <br /> ADDRESS Q l Y/ <br /> PHONE NUMBER !� <br /> CONTRACTOR .G-..L--�1--%!v <br /> CiTVIZIP G. 4f <br /> PHONE NUMBER <br /> i GEOGRAPHICAL INFORMATION; COORDINATES: X <br /> Y TOWNSHIP- RANGE <br /> l SECTION <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: <br /> ❑ NEW INSTALLATION NUMBER OF LIVING UMTS:' <br /> ❑ <br /> ❑ REPAIR/ADDITION RESIDENCE❑ CO RESIDENCE <br /> NUMBER OF BEDROOMS: <br /> Cl DESTRUCTION Ll OTHER NUMBER OF EMPLOYEES; <br /> ❑ ENGINEERED/ALTERNATIVE <br /> CHARACTER OF SOIL TO DEPTH OF 3'; <br /> PIT/SUMP SOIL CHARACTER: <br /> WATER TABLE DEPTH: <br />€ PERC TEST(S) HOW MANY O V O <br /> APPLICATION# V t+� <br /> ❑ SEPTICTANK TYPE/MFG <br /> GREASE AP TYPE/MFG <br /> CAPACITY. #OF COMPARTMENTS <br /> D <br /> CAPACITY #OF COMPARTMENTS <br /> ❑ Pf<GTX PLANT DISTANCE TO NEAREST: WELL _ � <br /> FOUNDATION PROPERTY LINE - C <br /> ❑ L1 FT STATION SIZE TYPE of PUMP �1 <br /> SAND OIL SEPARATOR(ENCLOSED SYSTEM) . <br /> ❑ LEACH LINE #OF LINES: LENGTH OF LINES: - <br /> E - DISFANCETONEAREST: WELL FOUNDATION - <br /> INFLITRATOR CHAMBERS: PROPERTYL[NE <br /> ❑ FILTER BED WIDTH LENGTH DEPTH DlSrnfYCETpNEAR&ST: WELL <br /> FOUNDATION PROPERTY LINE <br /> 0 MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL - <br /> FOUNDATION PROPERTY LINE —^I <br /> © SUMPS WIDTH - LENGTH DEPTH DISTANCE TO NEAREST: WELL - �—+ <br /> FOUNDATION PROPERTY LINE Cl <br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCETONEAREST: WELL <br /> . FOUNDATION PROPERTY LINE <br /> ❑ SEEPAGE PITS # - <br /> DIAMETER DEPTH DISTANCE TO NEAREST: WELL - <br /> FOUNDATION PROPERTY LINE <br /> — <br /> I HEREBY CERTIFY THAT I HAVE PREPARED . S APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS <br /> it,1�-- <br /> f AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, <br /> OU DVANCE NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)468-3423 <br /> SIGNED. <br /> _ rf 15 <br /> TITLE: Inr�z. DATE: <br /> I ! , <br /> .. <br /> I <br /> I <br /> . n <br /> ._. <br /> , <br /> Y ..-. .;_... L. <br /> i......... - A <br /> I <br /> 3. <br /> a-d <br /> 1 , I i <br /> II <br /> i... <br /> 1 <br /> "�� .�{,14r 1wr�pIT"c y-+Jsyip •bTI Y- -' � _ I ! I { I-yll',lti��l l�lJ���� <br /> Irw <br /> J�t1 H� 7 I ....� <br /> �, ern hl <br /> : <br /> DEPARTMEN <br /> T USE ONLY C t�J ,q <br /> APPI.FCATION ACCE Y: _ 1 %��REA EMPLOYEE IDN / r 1 DISTRICTz !CC` <br /> DATE: <br /> i LOCATION <br /> INSPECTED B DATE:f1/ /G`�. , <br /> PERMIT FINAL YES PATE: INSPECTO <br /> COMMENTS: �L <br /> PE CODE $C INFO AMOUNT C=SH RECEIVED <br /> REMITTED DATE PERMITlSERVICE REQUEST# INVOICEM <br /> BY SEPTIC MN <br /> . z 1 k� llSb � �{ aA pow+�� 3 <br /> I <br /> I <br /> REVCSED 1.15.01 <br />