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`w LIQUID WASTE PERMIT`/ 24 HR NOTI E <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E.WEBER AVE.,3R°FLOOR,STOCKTON.CA 95202 (209)468-3420 REQIJESTE <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FOR A L L <br /> �� �e���� �J' INSPECTIO S <br /> JOB ADDRESS 2327 !,!3 <br /> �J �j /J Q <br /> CITY(LIP /I� ftmQo PARCEL SIZE/APN ✓`--�f' <br /> l a` Dom" G / <br /> OWNER NAME 12a"12a" I . �OJOO�P D^ ADDRESSPA/TD_ 1 <br /> CITYlLIP� '' ifl <br /> 7 � PHONE _ <br /> CONTRACTOR E F-.l-�-l6m ADDRESS/4y 3f <br /> CTIY2IP12-07� <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE SECTION <br /> PERC TESTIS) (14"HOW MANY 2- APPLICATION#: <br /> I YPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 13 RESIDENCE ❑COMMERICIAL 13 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 TANK/GREASE TRAP TYPEIMFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL_ FOUNDATION PROPERTYLINE <br /> 13 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 PROPERTYLINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH - <br /> DISTANCE TONEAREST: 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 /> 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 LAWS ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. /? � �. /,.� �q <br /> SIGNED: lw� TITLE:�j�I t..�/�j� ! DATE: l� S U <br /> ro <br /> W �-- <br /> �� ' <br /> too. <br /> a <br /> IV <br />