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.3:3t <br />LIQUID WASTE PERMIT 24 H F -I fU C+.j._ l - <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RCCC)UES�TE <br />ALL—309 F_ WFZER AVE.. 3" FLOOR. STOCKTON. CA 9520' (2091468 3420 F (D R <br />NON—REFUNDABLE PERM��IT'EXPIRES I YEAR C MDATE .5' ;HI) I�� F-[_C"-i!'C.) <br />JOB ADDRESS -2-f ✓�I s 4�1j.�����1_ <br />CITY/711'- �SCti L+-,�J PARCEL SI JAPN q <br />OWNER NAME CEJ •SLI rfj " .__ADDRESS �I - <br />CITYIZIP_ ,4,y _ C.v\ Q 2 c-�- __ PHONE• <br />CONTRACTOR�� KaJ /AUUR£SS�Ltl "% v • �� <br />CITYfLIP �'r /� ?'IS 1^_ PHONE <br />GFIXIRAPHICAL INFORMATION: CWRllIANTES: X Y TOWHSHIP_RANGE`SECTION__ <br />PERCTEST(S)OHOW MANY APPLICATION!.:_ — <br />"IYPEOFSEMICINORK: ❑ NEWV4S'1'AI.IA'ITON REPAIRIAUUMON if DESTRUCTION <br />INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br />NUMBER OF LIVING UNITS:,_" NUMBER OF BEDROOMS'_ NUMBEROP EVWIAYEES :__ <br />CHARACTER OF SOIL TO A DEPIH OF FHE'f::iN PIT/SIJMP SOIL CHARACTER: _ WATER TABLE DEPT <br />G�SEPTIC TANK/GREASE TRAP 'I'YI'19MFG ��` CJNL�'e"Il:APACRY I°ZaJ NIIMBEROF•COMPARIMEATS_ _ <br />f <br />11C-13;; PKG TREATMENT PLANT DISTANCETONEAREST: WELL FOUNDATIONPROPERTYLJ.YEl- -J' <br />❑LIFTSIATION SIZE TYPEOF M(MI' SANDOILSEPARA"IOR(ENCLOSED SYSTEM) <br />❑ LEACHING LINE NUMBER & LENGTH Of I.INF.ti J INFILTRATOR CHAMBERS <br />DISTANCE TO NGARFS'I': WELL FOUNDATION-_?ROPERTY LINE <br />❑ FILTER BED WIDTH LEVGTH DEPTH <br />DISTANCE TO NEAREST: WELL-,- FOUNDATION:_ PROPERTYLIFIF?"-,la/'i I, <br />11 /r•r <br />❑ MOUNDED WID'TII --_ LENGTH --DEPTH <br />DISTANCE TO NEAREST: WELL FOUNUA110N PROPERTY LINE.. <br />O SEEPACIF. PITS WIDTH _ LENGTH --DEPTH _ t <br />UISTANCETONEAREST: WELL FOUNDATION PROPERTY,"I�AI' I" 1 N - <br />❑SUMPS WIDTH LENCT11 DEPTH <br />DISTANCETONFARYST. WELL FOUNDATION PROPERTY 1.1 NE <br />❑DISPOSALPONDS WIDTH LENGTII DEPTH _ <br />DISTANCE TO NEAREST: WELL ____ FOUNDATION PROPERTYLINE <br />I HEREBY CERTIFY TH:YT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />OKDIANC'FS, STATE. LL.Pl`S, -III' RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. {� <br />SIGNED: / / /^�'� TITLE, Dlgjr C/� DATE r Y <br />� I <br />lkfI <br />JAI d <br />I <br />p11S AA E Er�T t <br />i <br />7+-41 Yl AVI-f <br />FUR DEPARTMENT LSE UNLY <br />L }� <br />APPLI :A'['ION A(:r'P.PFF•O BY <br />TANK. PR. OR SUMP INSPECTED BY: <br />JINAL INSPFCT'ON BY: <br />oor <br />COMM <br />i <br />PE E AIYI111.\ I' THECA n; RECEI\'ED 01 DATE PCRMMSERV'ICE RVQUr ti l' • SEPTIC 10 <br />IN <br />FO RiM,l' CASH <br />WE <br />t= <br />Cj <br />0 <br />v } <br />Ift <br />