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LIQUID WASTE PERMI <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> 24 HR N©TICS <br /> ( <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED H EG?U ESTE I] <br /> JOB ADDRESS % U J ✓ rD <br /> CITY/ZIP SIO 4r.-%d1J r C4 �Z� PARCEL SIZE/APN ` 3 <br /> OWNER NAME A L7 s/e7� ADDRESS 0,D -d o X 4/7S- <br /> 2576CACZ [rN <br /> CITY/ZIP SID C 11' �� PHONE 2--4f <br /> CONTRACTOR ADDRESS <br /> CITY/ZIP xhk\ffPHONE <br /> GEOGRAPHICAL INFOR TION: O : X Y TOWNSHIPRANGESECTION <br /> PERC TEST(S) ( ) HO Y APPLICATION k: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑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 TYPE/MFG CAPACITY 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 /> ❑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 /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIF IAT I HAVE PREPARED TII� PLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,S A LAWS,AND RULES ANDD RE <br /> GULATIONS OF SAN JOAQUIN COUNTY. / <br /> SIGNED: TITLE:C�C��,U-� ` �*-DATE: Z(O/Z�yv <br /> tio <br /> p . <br /> 1 <br /> 7U.1 <\c U1N CV M) <br /> 'Wc,, <br /> V � <br /> Ir <br /> FOR fitPART E T 'E ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> TANK,PIT,OR SUMP INSPECTED Y: DATE:_ <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> -614';CA� -fij2otn ?�d e .4�W44 LW <br /> =(� <br /> PE CODE SC AMOUNT HECK# RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO REMITTED CASFI <br />