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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICF_S ENVIRONMENTAL HEALTH DIVISION <br /> 304 E WEBER AVE..1°"PLOOR•'DCKTON.CA 952W (209)468-3420 <br /> NON-REPUS PIE PERMITpEXP M I YEAR FROM DATE IS UED <br /> JOB ADDRESS 15 <br /> �+._..�_^�/i� T ^p <br /> CITY2IP� ZAP _PARCELSI27JAPN <br /> / OWNEY NAME_.. - (�"CA-'��Nl .__�."u=. ._ADDRESS <br /> y CITYMP _!,PHONE <br /> CONTRACTOR ADDRESS_-_ _ <br /> CftY2lPPHONE _ <br /> GEOGRAPHICAL.INFORMATION:COORDIANTFS: % Y TOWNSHIP—RANGE—SECDON__ <br /> PERC TESTIS)( )HOW MANY APPLICATION K:_ <br /> TYPE OF SEPTIC WORK.: ❑ NEW INSTALLATION O REPASRIADDITICN4 L7'ITM7C eft OUT OF S"cs <br /> INSTALLATION WILL SERVE: ❑RESIDENCE O COMMERICIAL ❑OTHER— <br /> NUMBEROFLIVING UNITS.-,_ NUMBER OF BEDROOMS_ NUMBER OF EMPLOYEES:— <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET. PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANKIGREASE TRAP TYPE/MFG CAPACITY NUMBER OFCOMPARTMF.NTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELT. FOUNDATION — PROPERTY LINE <br /> ❑UPI STATION SIZE— I YPF:OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACHING LINE NUMBER&LENGTH OF LINES ! INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION -ROPERTY LINE <br /> 0 FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE FO NEAREST:WELL FOUNDATION:_ PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCETONUAREST: WELL _. FOUNDATION PROPFRTYLINB_.. <br /> ❑SEEPAGE PITS WIDTH L0gGTH —DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION _PROPERTY LINF <br /> O SUMPS WIDTH LENGTH _DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> Q DISPOSAL PONDS WIDTH LENGTH DEPTH _ <br /> DISI'ANCF.TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STAT WS,AULES AN S OF SAN JOAQUIN COUNTY. A �! <br /> $Ic NED TITLB:(l1 DATE <br /> to <br /> t I _L <br /> 44 <br /> j a � • <br /> LF <br /> • <br /> —! <br /> FO EPA M SE ONLY <br /> APPLICATION ACCEPTED BY: DATE: - � <br /> TANK.PTT.OR SUMP INS Y: <br /> FLNAL INSPFL-PION BY: <br /> COMMPN i8: _� <br /> PE CIODF. Sc AMOUNT CIMC:K+! RECOVEDBY DATE- PERMITISPRVICE REOUESTY SEPTIC IDP <br /> ,L INPO REMrrrrD I CASH <br />