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LIQUID WASTE PERMI <br /> SAN JOAQ,-..R COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 'ALTH PtLV[S ON, <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-342W-' " fi <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> JOB ADDRESS '-13(Z STr TC <br /> CITY/ZIP PARCEL SIZE/APN 3CYv. !S A 0.257 "0$�O-- 0'2 <br /> OWNER NAME S �N LJT� ADDRESS �=7J 5- ti1 I l,l�S X Cly <br /> CITY/ZIP Lr+h GG <br /> 1 -I S Z PHONE <br /> CONTRACTOR__ NEIL O, f3NQ�'LS�+N /f'/fJ� i15k , <br /> ADDRESS ZZ Jt)U.r i-Z:& L­I�E: <br /> CITY/ZIP ('00 ( CIS 24 0 PHONE_ 2100) - 36 1 T701 <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGE_SECTION <br /> PERC TEST(S) ( ) HOW MANY i APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW 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 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 I INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑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 /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> v <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 AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: TITLE: p96��lV%Ia'f^1. DATE; ( 2 <br /> S 4 <br /> I• <br /> O <br /> O <br /> 0� QOr <br /> t V.6 <br /> TO <br /> 17 16 9 NJ '� rr Ir- - <br /> TERYIMOUS ROAD ' e 16 13 Ot �-1V hI1` 41('•.11 Vii' .•,'III':I, <br /> ­T[q IACIIIC R11LIgAp CO, I�.• <br /> 9k. I <br /> 55, <br /> ------ = / <br /> FOR DEI'ARTMEI�7'17SEONLY <br /> / <br /> APPLICATION ACCEPTED HY: DATE: � /�(/""G.. <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE: <br /> FINAL INSPECTION BY: , <br /> ` r <br /> COMMENTS: 30 Phi <br /> M IU N ,•.S <br /> PE CODE SC AMOUNT CHECK RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO REMITTED SH <br />