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LIQUID WASTE PERMIT 24 HR rq CDT-1 <br /> SAN JOAQlnry COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL nnALTH DIVISION pC <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 1--11 1___Q U E 1T <br /> E <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FQ R Al L <br /> -TIC I <br /> JOB ADDRESS rA 0C <br /> VA <br /> ,3 f <br /> + <br /> CITY/ZIP �.. 1z � .Z, PARCEL SIZEIAPN <br /> OWNER NAME: `!_' r-' C`� f iLi, VIII ADDRESS <br /> CITYIZIP :.fi lwr ..r I _ PHONE f7 I <br /> CONTRACTOR &.A.)n f.+� s <br /> o,4)A I i3 O&L r)1/tJ� ADDRESS <br /> CITY/ZIP `✓f-' 1`L.? i�. _7 1 PHONEL;7 I W <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP, RANGE''�SECTION I/ <br /> PERC TEST(S) (,.4 HOW MANY_ APPLICATION#: r <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑9THER <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 /> 3 <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I ❑LEACHING LINE NUMBER&LENGTH OF LINES ! INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ®®[9/ �/^^vv Civ <br /> El FILTER BED WIDTH LENGTH DEPTH R E C E I V E E4 <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE q ,a <br /> ❑MOUNDED WIDTH LENGTH DEPTH JUN 0 4� irrryry9 j� I <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LlyXN_4qA.a8fi+C4UNTY <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION 3. HROPERTY L[WE,' <br /> i ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> s, <br /> . DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> E-' <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 LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY.' r' ' <br /> SIGNED: r:!l` f '•ror' IT :,.4'4'.1 t! "w DATE <br /> 7 <br /> 1 <br /> I � <br /> t <br /> 4^ ; <br /> t � <br /> { , Y <br /> f <br /> v " <br /> I r 1 1 <br /> j 11 <br /> .,A <br /> i <br /> 1 <br /> { <br /> 1 <br /> t , <br /> FOR DEPARTMENT USE ONLY <br /> L <br /> DATE: 8 t... <br /> l APPLICATION ACCEPTED BY: b / — <br /> "A TANK.PIT,OR SUMP INSPECTED L <br /> FINAL INSPECTION BY: • t ---- <br /> d' COMMENTS: L4. --- <br /> - ---- <br /> PE CODE SC AMOUNT CHECK#/ RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC BNI <br /> T INFO REMITTED CASH` /I <br /> , km" <br /> �, <br />