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- ; LIQUID WASTE PERM!
<br /> :OAQUIN COUNTY PU9LIC HEALTH SERVICES ENVIRONMEh HEALTH DIVISION
<br /> t 304 E.WEBER AVE 3"°FLOOR,STOCKTON,CA 95202(2L,� 9.3420
<br /> Ik NON.REFUNDABLE PERMIT EXPIRES I YEAR FROM D7 EIS UED
<br /> l JOB ADDRESS { APN PARCEL SIZE:�trC�
<br /> CITYIZIP 4,69d, , C O BUILDING PERMIT k
<br /> OWNER NAME 6'l. ADDRESSe'7v �^7
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<br /> CONTRACTOR ADDRESS
<br /> CITYIZIP PHONE NUMBER
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<br /> GEOGRAPHICAL INFORMATION: COORDINATES'. X Y TOWNSHIP RANGE SECTION
<br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: # NUMBER OF LIVING UNITS:
<br /> f 0 NEW INSTALLATION ❑ RESIDENCE NUMBER OF BEDROOMS:
<br /> i{ Cl REPAIR/ADDITION ❑ COMMERCIAL NUMBER OF EMPLOYEES:
<br /> ❑ DESTRUCTION ❑ OTHER
<br /> 1 ❑ ENGINEERED/ALTERNATIVE I
<br /> CHARACTER OF SOIL TO DEPTH OF 31: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH:
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<br /> { ❑ PERC TEST(S) HOW MANY APPLICATION#
<br /> ' ❑ SEPTIC TANK TYPEIMFG CAPACITY #OF COMPARTMENTS
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<br /> I ❑ GREASE TRAP TYPE/MFG CAPACITY #OF COMPARTMENTS
<br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION } PROPERTY LINE
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<br /> ❑ LIFT STATION SIZE TYPE Of PUMP- SAND OIL.SEPARATOR(ENCLOSED SYSTEM)
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<br /> ❑ LEACH LINE #OF LINES: LENGTH OF LINES: DISTANCETONEAREST: WELL FOUNDATION PROPERTY LINE
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<br /> INFLITRATOR CHAMBERS:
<br /> ❑ FILTER BED WIDTH LENGTH DEPTH DKTA14CIKTONEAREST: WELL FOUNDATION PROPERTY LINE
<br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> ❑ SUMPS WIDTH LENGTH DEPTH OISTANCETONEAREST: / WELL FOUNDATION PROPERTY LINE
<br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCE TONF.AREST: # WELL FOUNDATION PROPERTY LINE
<br /> ❑ SEEPAGE PITS # DIAMETER DEPTH DLSTANCETONEARESF: } WELL FOUNDATION PROPERTY LINE .�
<br /> I 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. t.1
<br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)469-3423
<br /> SIGNED: +TITLE: DATE: .�
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<br /> . � DATE. V AREA�EMPLOYEEID4AOa TI
<br /> S APPLICATION ACCEPTED BY: _ DISTRICT LOCATION
<br /> INSPECTED BY: DATE: PERMIT FINAL❑ YES DATE: INSPECTOR: -
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<br /> COMMENTS:
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<br /> PECODE SCINPO AMOUNT CHECK#!CASH. RECEIVED DATE PERMITISERVICE REQUEST# INVOICE# SEPTIC IDM
<br /> REMITTED BY
<br /> �z -17677
<br /> REVISEDA-15-01
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