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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3'0 FLOOR.STOCKTON.CA 95202 (209)468-3428 2-1 <br /> 1 <br /> WON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED :-L_. <br /> 2322 3 S. A�u>z�� Roams Rc C'a . 9s3s4� ��`rt .r i <br /> JOB ADDRESS <br /> C <br /> CN> PARCEL SIZF/APNy� <br /> cori 40 23203 5 . Iasis-r'n �a <br /> OWNER NAME ADDRESS q C- <br /> CITYIZIP IZ\\�L'11��n (�� r��..�� �y�]CPHONE a { 7 q-299G <br /> CONTRACTOR <br /> (�/��C.Y k �"p l 7 �.`�hj_'yQ*L_�1N?"`_o�1! ADDRESS tag NY�•� <br /> CITYr/IP 1'`&�T� R53s7 PHONI(I 0-1,) S2 T^49 <br /> GEOGRAPHICALINFORMATION:COORDIANTES: X Y TOWNSHIP_RAANGE_SECTION <br /> PERC TESTIS)pp HOW MANY APPLICATION M: ms- <br /> TYPE <br /> I-TYPE OF SEPTIC WORK: El NEW <br /> NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE. ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNrTS:__ 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 TANKIGREASF 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 LINJE NUMBER&LENGTH OF LINES ! 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 UNE_ <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 HERE Y CERTI THAT 1 HAVE,PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN STA LA S, D RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. /�� 8 I Q 1 <br /> SIGNED: .� TITL �� rc�.►61��+E'r1S DATE: f <br /> MGLW <br /> I L# <br /> i • f• • • •f• 0 • •f• • •f* • <br /> • • s e • e • • • • • • • • • 1A <br /> • • o . • • • s • o • • • • • <br /> • • • PAROL 2 • • • • • • PAR= 1 <br /> • . • • • • 0 o • . • • •w . ,J. <br /> • • • o • e0 is go 0 <br /> • �� � • • aGpO�()p� � � <br /> �O ;2 <br /> •�l�. • • • • • • • s • • • =o �M• )J <br /> 1 Ci' saa., ��,,,• <br /> +H <br /> wt <br /> `A p\ <br /> } <br /> t�pR DBPARTMPIYT BONLY <br /> _. _ �0 G <br /> APPLICATION ACCEPTED BY: (. DATE <br /> TANK.PIT.OR SUMP INSPECTED BY: DATE: <br /> FINAL INSPECTION BY <br /> COMMENTS: <br /> PECODE SC AMOUNT HECK RECEIVED BY DATE PERMITISERVICEREQUFSTM SEPTIC IDN <br /> REMITTED H <br /> o oCJ <br />