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_._ ,� .H.., .►�- LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SFRVIC'.ES ENVIRONMENTAL HFAIA-H DIVISION <br /> 301 E.WEBER AVE..3RD FLOOR.STOCKTON,C.1 95202 (21)9)468-1.720 24 H R "d--r'C <br /> NON•RFF IND,1 BLE PF,RV E.?PIRFS I YFAR FROINI DATE IME R E Q U E S, E ED, <br /> JOB ADDRESS <br /> a � t �ep FC)R ALL._ <br /> INSPEr, iCiN <br /> r_n'YnIP� q,�ao� r Itc'Ft.slzE�.aPN_. _ <br /> OWNER NAME �15�(�I1'1 ( GG1_IY1�ADME.SS lJ 3GSt� _ <br /> CITYtZIP_ 4 PHONE <br /> CONTRACTOQIV <br /> CITYrZIP � L ' gs <br /> _E ✓S70 P.HAODNDCR_ESS'"�ZU 441 —p�0!!J/� W <br /> GEOGRAPHICAL INFORMATION: COORDIANTF.S: X Y_ TOWNSHIP—_.RANGE_SFC'TION__ <br /> PERC TESTS) ( ) HOW MANY _ APPLICATION N: <br /> TYPE OF SEPTIC WORK: O NEW INSTALLATION ❑ RFPAIR/AI)1)I'1'I0N DESTRUCTION <br /> INSTALLATION WILL SERVR: O RESIDENCE ❑CONINIIRRICIAL O OTHER _ <br /> NUMBER OFLIVINO UNITS:-- NUMBER OP BEDROOMS:—_ NUMBER OF EMMOYEES— <br /> CHARACTER OF SOIL TO A DEPI H OF 3 FEET': _ PIT,SUMP SOIL CHARAC'I'ER: _ WATkR'I'ABLL DEPTH�_- <br /> ❑SEPTIC TANIUGRP.ASE TRAP 'TYPE-'MFG— _CAPACITY NIIMBF14 OF COMPARTMENTS <br /> OPKGTREATMENTPLANT DISTAN(TTONI-AREST: WELL FOUNDATION PROPERTY LINE . <br /> ❑LIFT STATION SIZE __ I YPF OF PUMP- SAND 011,SEPAR,,TOR(ENCLOSED SYSTLM) <br /> O 1 FACI IING LINE. NUMBER&LENGTI I OF LINES--/—. INFILTRATOR CHAMBI•:RS <br /> DISTANCE TO NEAREST: WELL ' FOUNDAIlON__ PROPERTY LINE <br /> O FIL•I'FR BED WIDTH LENGrti __ DEPTH <br /> DISTANCE TO NEARFST: WELL_ _ FOUNDATION, PROPERTY LINE — _ <br /> O MOUNDED WIDTH LENGTH_ DEPTH <br /> DISTANCE TO NEAREST: WT LL FOUNDATION PROPERTY LINE <br /> ❑SLETA(F PITS WIDTH _ LENGTH DEPTH <br /> DISTANCE TO NFAREST: WELL FOUN.)A I ION -- _ PROPERTY IJNE <br /> ❑sUSIPS WIDTH LENGTH 7EIn')1 _ <br /> DISTANCE TONGSRF_ST: WELL PJUNDATION . _PROPERTY LINE <br /> ❑DISPOSAL PONDS R'IDT}i LFN6I'H I)FP'1'H <br /> DISTANCE TO NEAREST: WELL FOUNDATION _PR()PHR TY I.INE _ <br /> 1 HEREBY CERTIFY THAT I IIAVF PREPARED THIS APPLICATION AND THE WORK WILL BY DONV,,IN ACCORDANCE WITH SAN JO.AQUIN COUNTY <br /> ORDIANCKS,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQ!IN COUNTY. <br /> SIGNED.—___ Ll I <br /> T <br /> FT <br /> ICL <br /> - – — ++ <br /> S <br /> n <br /> U14 <br /> i4T� 47)1 Fr I <br /> 'F I - 1 —1 1 � ' i TI <br /> I <br /> Eau D PARTMENT USE o.t.Y <br /> APPLICATION <br /> __ _ _ _ DATE: ... y <br /> ACCFYI hU DY: .— --- <br /> _— _ _ 1)ATr:- —� �- <br /> TANK,PIT.OR SUMP INSPECTED Y"�. / _ - <br /> MNALMSPLCTIONLY_i ,�/1�/i�3' — <br /> COMNM'`TS-_ <br /> PF:COf)1-. SC AMOUNT CC' RF.CPIVLD DY CATG PERMI'f1SPJiVICE RFQIJF_STR SEPTIC II>a <br /> INFO RrMIT-I'FI) SH <br /> ) <br />