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LIQUID WASTE PERMI T��// <br /> SAN JON COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTALRkF.ALTHDNISION <br /> 304 E.WEBER AVE.,3°O FLOOR,STOCKTON,CA 95202 (209)368-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS AlIGC �� t.>' � DI <br /> /'') <br /> CITY/ZIP '&0'L C45-L4, - : PARCEL SIZE/APN ' 1 -v ` <br /> OWNERNAME ,TI'ILw�CSJ� ADDRESS aRY� •y �� <br /> CTTY/W Sto�C.�._I Q`,51�� PHONE �L�•glb"S <br /> CONTRACTOR��OS�� ...1 LI..� DISC ADDRESS �VtI <br /> CITY/ZIP �r AS-Lm PHONE Yob ' $OQiB <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE SECTON <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEWINSTALLATION ❑ REPAIR/ADDITION x DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES:— <br /> CHARACTER <br /> MPLOYEES:CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PTT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYP&MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PRO TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 13 LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(EN 7) <br /> 13 LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRA CP I R E <br /> DISTANCE TO NEAREST: WELL FOUNDATIOrPefjjj#_ffl-1 11"''OLM13ifp�.�j}hout <br /> ❑FILTER BED WIDTH LENGTH DEPTH work being completed or inspected <br /> DISTANCETO NEAREST: WELL FOUNDATIQN�:) PROP I <br /> 13 MOUNDED WIDTH LENGTH DEPTH 7' Ln�lr�me„Lal ealth-ivision <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATJON PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES, ATE LAWS,AND RULES <br /> /AND REGULATIONS OF SAN JOAQUIN COUNTY. n ' <br /> SIGNED: �JZ �_ - [�JN- TITLE:L�G.L"A. ��!/'9/ <br /> Fr <br /> V ` <br /> v _ r <br /> S <br /> N EN .L+'AL LII 31 N <br /> FOR DEPARTMENT USE ONLY <br /> APPUCATION ACCEPTED BY: DATE: <br /> TANK.PIT.OR SUMP INSPECTED BY: DATE: 3 <br /> utv <br /> HNAL INSPECTION BY: �I 9 <br /> COMM : <br /> PE CODE SC AMOUNT CHEC RECEIVED BY DATE PERAT 5ERVICEREQUEST# SEPTIC BJ# <br /> BVF R" <br /> `1 <br /> Lw 'f (j �V� �1 z'3 0-/Aj- n_.j Ts 6Ld `n v�e <br />