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LIQUID WASTE PERMII, .., 214 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> ` 304 E.WEBER AVE.,3p°FLOOR,STOCKTON.CA 95202 (20))468-3420 <br /> tt 7 NON-KF:FUNDABLE PIiRMIT EXPIRES 1 YEAR FROM DATE ISSUED 'N T�t© <br /> JOB ADDR ✓ VL <br /> CITY`/ZIP /�/� >/!�/V ry _ PARCELSIZFJAPN <br /> OWNER NAME t -�z ADDRESS y3 �rxJ�li4J• <br /> CITY/ZIP ��� � � PHONE <br /> CONTRACTOR ADDRESS <br /> CITYIZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP RANGE SECTION <br /> PL'RC TEST(S) ( ) HOW MANY APPLICATION 8: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIWADDITION DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE XCOMMERICIAL !❑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/GREASETRAP TYPElMFG CAPACITY t 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 /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> Cl MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> Cl 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 /> 1 HEREBY CERTIFY TH T 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STA REGULATIONS OF SAN JOAQUIN COUNTY. /j� / <br /> SIGN' TITLE:_ r <br /> � // .�I(� ATE:(/ ��l4 <br /> V + <br /> O \ <br /> G\G ` OFF <br /> 'o'd <br /> r <br /> S Fl <br /> }tk;PAR" E U,' LY (a(1 T <br /> PL ATION ACCEPTED BY: DATE: W <br /> TANK.fIT.OR SUMP INSPECTE B �` - DATE:_ <br /> FINAL INSPECTION BY: - <br /> C19- I <br /> COMMENTS: "A -- <br /> w� r U • <br /> PECODE SC AMOUNT &jEL4W RECEIVED BY DATE PERMIT"/SERVICE REQUEST N SEPTIC IDN <br /> INFO REMI CASH <br /> C c�3� l3 Da <br />