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LIQUID WASTE PERMIT <br />SAN JOAQUIN COUNTY,PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />304 E WEBER AVE- 3" FLOOR, STOCKTON, CA 95202 (209) 468-3420 <br />f <br />ANON -REFUNDABLE PERMIT EXPIRES I YEAR PROM DATE ISSUED <br />JOB ADDRESS Al t OO _� �+! �. ---- _ - <br />CiTYILIP__��w/'+�. -1 "1''51 rf PARCE[. SIZFJAPN 1' 1 q � I � � � � - <br />OWNER NAME �R. T'IL�. c.L..E/� ADDR1;-';) <br />CTTY(Z1P 5.-,,,C.C.'a A- d.1o"S PHONE %j�.. Ql t b $ <br />CONTRACTOR OJ LA..J141-1�� XN(t-. ADDRESS -.Lf -l'% i , oow• L . <br />CITY/ZIP ��- ot.K-'ha� Ci'S Z•�e S PHONE�,__!�1 � � 9�Sa <br />GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHTP_RANGE SECTION <br />PERC TEST(S) I )HOW MANY APPLICATION 0: <br />TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REP.AIRIADDITION DESTRUCTION <br />INSTALLATIONWILL SERVE Cl RESIDENCE ❑ COMMERICIAL ❑ OTHER <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 TANKJGREASE TRAP 7YPFJMFG CAPACITY NUMBER OF COMPARTMENTS____.____., <br />Cl PKG TREATMENTPLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />❑ LIFT STATION SIZE. TYPE OF PUMP SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACHING LINE NUMBER & LENGTH OF LINES ! INFILTRATOR CHAMBERS - _ __ - <br />DISTANCE TO NEAREST. WELL FOUNDATION PROPERTY LINE _ <br />❑ FILTER BED WIDTH LENGTH DEPTH <br />DISTANCE70 NEAREST: WELL FOUNDATION:-- PROPERTI' LINE <br />❑ MOUNDED WIDTH LENGTH DEPTH <br />DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINB___.. .- <br />❑ SEEPAGE PITS WIDTH LENGTH _.._ DEPTH <br />DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE _ <br />❑Sumps WIDTH LENGTH___.. DEPTH <br />DISTANCE TO NEAREST: WELL _FOUNDATION PROPERTY LINE <br />O DISPOSAL PONDS WIDTH ___ LENGTH DEPTH <br />DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDIANCPIS„[{TATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. /� <br />s1C,NIiD:. Y-3-•��i.. LM✓�- ............___ TITLE:C.�4h..-T <br />5 <br />._............. <br />AN 0 J TY <br />w <br />16 VI S <br />I I <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY: _ ATB'--- <br />TAMC PIT, OR SUMP INSPECTED BY: /-I} <br />FINAL INSPECTION B Y: _ 1-- -j <br />COMMENTS: <br />PIi CODESC AMOUNT CHBC / RFCEIV'EDRY DATE PERMroSERVICER EQUESTM SEPTIC IDY <br />INFO R8M1 _ <br />��� i 11 dl�� O <br />i <br />:''aij L4U-S-3 <br />: 1U1rt- <br />r / .;G <br />1 /7 <br />