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�-' LIQUID WASTE reRbIIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DI\�S10N _ <br /> 301 E WEBER AVE.,3RD MOOR,STOCKTON.CA 9520_ f2091468-3420 4 HR <br /> `- `� N0N-REFUNDARLF.PERMIT EXPIRES I YEAR FROM DATE ISSUED R F-_ _ '-' �--' <br /> 108 AUDRFSS - <br /> c /�/� ..- _ <br /> CITY,7iP _SSA I� 2 jar.Yl PPAARCELSIIZJyPNOl 'C <br /> OW'%TRNAME I1a <br /> PHONE <br /> CONTRACTOR IDI C~- t�Nr�.[l( ''�-,�J� 1 f�. ADDRESS, �C2Yt `�. <br /> ClTY121P 1 C��I �I 4 �t Uy PHONE_:�C I/ 3(O/' aJ�V T <br /> sy GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP_RANGE_SSIEC IOON <br /> PERC TESTS,/IHOW AI.ANY l .APPLICATION n 4'I� _Q <br /> Q c I C1`' ` <br /> C; <br /> TYPE OF SEPTIC N'ORIC: ❑ NEN'INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES <br /> CHARACTER OF SOB.,TO A DEPTH OF 3 FEET: Plt/SUA1P SOIL CHARACTER: WATER TABLE DEPTH <_ (-�- <br /> ❑SEPTIC TANK/GREASE TRAP TY-PENIFG CAPACITYNUMBER OF COMPARTMENTS .� <br /> U <br /> ❑PBG TREATMENT PLANT DISTANCE TO NEAREST: N"ELL FOUNDATION PROPERTY UNE C7 <br /> ❑LIFT STATION SIZE TYPEOFPUMP SAND OIL SEPARATOR(ENCLOSED SYSI'EMI <br /> ❑LEACHING LINE NUMBER S LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE "r <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISI'.ANCE TO NEAREST. WELL FOUNDATION PROPERTY UNE_ <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOCNDATION PROPERTY LINE <br /> 1 <br /> ❑SUMPS WIDTH LENGTH DEPTH z <br /> DISTANCE TONEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY TIIAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE IA ITH SAN JOAQL'IN COUNTS <br />�. ORDIAN LAWS,.AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGN 1 _ 't TITLE: I-��l'/R'�I Sr DATE: <br /> i I IIN <br /> 771.I I 1 1 1 1 <br /> Am 1 <br /> 1z' ITPf"1I Ell I I I <br /> II I I I I <br /> I II ! it I I i <br /> i I <br /> I I <br /> I <br /> I ! I <br /> II <br /> I <br /> I li <br /> I i <br /> SAN JaIAIIIIINN <br /> MCI <br /> - I E[h9P. P[tal.ffiA-,H£LR DIl' 101 <br /> In,'' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY:�)�XA DATE <br /> TANK PR.OR SLTIP INSPECTED BY: GATE. <br /> FINAL INSPECTION BY: <br /> COMMENTS. <br /> PE COD£ Sf AMOUNT C' RECEI\'EDBY DATE ('ERMIT;SER`:ICE REpCEST• SEPTIC ID. <br /> �1 (NFO RcA1[RED SH o <br />