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LIQUID WASTE PERMIT 11yo <br /> `,I U SAN JOAI/u1� UUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEPs1 H DIVISION -- <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> 24 <br /> HR <br /> i <br /> NON RFFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FR E= <br /> 'r""' - <br /> JOB ADDRESS !/ T DY G (� <br /> OLv Y 10Fw <br /> CITY/ZIP Ltxo i / 952¢0 PARCEL SIZE/APN 20 1 O F <br /> OWNER NAME LAW-/ �W- 111L/ ADDRESS F_• m`K-A y- 40�� <br /> CITY/ZIP �0 j _P5240 PHONEt p l ���3 14:5 <br /> CONTRACTOR v i4 owy, ADDRESS Pep. Box 2I A7 <br /> �6"7•• <br /> CITY/ZIP � / / PHONE 2o)) � -66/ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP NGESECTION <br /> /• <br /> PERC TEST(S) HOW MANY- APPLICATION r pA V 2 <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL <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 TYPEIMFG CAPACITY NUMBER OF COMPARTMENTS O <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Cl LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION °ROPERTY 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 /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES, A L7=REGULATIONScSAN JJOA�QUIN COUNTY. � I )7 <br /> SIGNED: _ry 1 - "l L�r�'f� TITLE: h {1 t`D►•� 45 { 1�SDATE: 11 r '~-C z <br /> i1 <br /> h <br /> O <br /> Q <br /> j; <br /> a- N <br /> Sti �1 41. <br /> r - - <br /> 1464 <br /> APPLICATION ACCEPTED BY: FOR DEPART <br /> DA <br /> TANK,PIT,OR SUMP INSPECTFp.B'I"' DATE: <br /> FINAL INSPECTION <br /> COMMENTS: <br /> PE CODE SC AMOUNT CHECK N/�• RECEIVED 6- DATE <br /> INFO RI.M I'ITED PERMTI'/SGRV ICE REQUEST N SEPTIC IDN <br /> yz.z :!�2 1� , 2-1 �r d oa 3 <br />