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y <br /> ` �► �, `., LIQUID WASTE PERMIT _ <br /> SAN JOAQUIN COUNTY PUBLIC HEAL'T'H SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WE13ER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 RE <br /> / NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FCD p" � L <br /> JOB ADDRESS ` �' i% / I- I ,> (N S E CD °' S <br /> 1 <br /> CITY/ZIP ) PARCEL SIZF/APN <br /> OWNER NAME_-•� _ _AI CRESS <br /> CITY/ZIP �✓ /h _ PHONE <br /> Lel SS <br /> CONTRACTOR A D D It I itis <br /> CITY/ZIP ,�`� , 7a-^- PHONE_ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGE SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION N: <br /> TYPE OFSEI'TIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION Ja' 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 / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> Cl 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 G <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 LAY AND RULES AND REGULATIONS N JOAQUIN COUNTY. ,A <br /> SIGNED: G �% ,r��' �r� • TITLE:_{ -t' <br /> DATE: <br /> v <br /> . 1 <br /> 1 <br /> ^A jC <br /> "Clio OI, TY <br /> l <br /> FOR DF.I'ARTMEN'T USE ONLI' <br /> DATE: —';I'SlI 0 D <br /> APPLICATION ACCEPTEDBY:_-��'�1' <br /> VV ul <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE:_ <br /> /U Ott <br /> FINAL INSPECTION BY: <br /> � 5 <br /> COMMENTS: L <br /> DECODE SCAMOUN"f ll'CR RECEIVED BY DATE PERMIUSERVICE REQUEST N SEPTIC IDN <br /> INFO REMI'IT:D 1 <br /> 224 X-6 s 00 i5ct <br />