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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3RD FLOOR,S OCKTON,CA 95202 (209)468-3420 <br /> �7- NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS_ —5Aj <br /> CITY/LIP <br /> //�� � PARCEL SIZEIAPN <br /> OWNER NAME (��7T N/\ �a�� ADDRESS <br /> t ' <br /> t` CITY2IP <br /> PHONE <br /> CONTRACTOR <br /> - ADDRESS <br /> CITY/ZIP <br /> PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X <br /> Y TOWNSHIP--RANGE—SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ &pTrRmTm 0 U 0 <br /> F SCFVj[c <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL <br /> 13 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br /> NUMBER OF EMPLOYEES:- <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: <br /> PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH_- <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY <br /> 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 /> E3LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE _ <br /> 13 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 /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑sumps WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> r.. DISTANCE TO NEAREST: 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 <br /> ORDIANCES,STATE WS,A ULES AN OTJ9NS OF SAN JOAQUIN COUNTY. <br /> SIGNED: TITLE:' V(! <br /> DATE: <br /> 13-3 a <br /> low <br /> J <br /> _- --I-- -- - - _ <br /> -- <br /> SQ <br /> Ic cxl <br /> -- -- <br /> _�-t <br /> : - <br />