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LIQUID WASTE PERMIT S v_ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 24 FIR <br /> � <br /> .� w <br /> �./ NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> O 'l /� .%AGK %NE /2b. FC)G L L <br /> JOB ADDRESS / `,h �•^ // 30 <br /> ^ , <br /> CI'I'Y/ZIP L-yyC��J�I 0 5 y PARCEL SIZE/APN� � Y/�4 !6 —� ,y S <br /> OWNER NAME POPE cJ�I�Ia9EQj u/TL7 ADDRESS �Z;k©g f /V -,IA CK Tz/Va- <br /> CITY/ZIP LGA D I PHONE 7 <br /> CONTRACTOR L!�F y /y 4 1I-S EAC{'Il ADDRESS R 0, 1309 3 'lq �p ` <br /> CITY/ZIP q S _4!0 I PHONE lr 5 T 0-3 <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP RANGESECTION <br /> PERC TEST(S)1Sp HOW MANY "_7 APPLICATION#: <br /> T'YPEOFSEPTIC WORK: /❑\NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE Cl 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 /> ❑SI?PTICTANK/GREASE TRAP TYPFJMFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARA'TOR(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 /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <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 /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIF IAT I HAV' AIRED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STYE J q WS,A AND REGULATIONS OF SAN JOAQUIN COUNTY. /,�{-� <br /> SIGNED: !� IXC/GTITLE:_b� DATE: <br /> I <br /> a. <br /> 1 <br /> 6A,A J"'/,U W .OU 4YY <br /> TA. HE I.T4 DI I.SIC r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATG. <br /> TANK,PIT,OR SUMP INE D Y: _DAT" L <br /> FINAL INSPECTION BY: <br /> COMMENTS: / <br /> PE CODE SC AMOUNT fliECK V RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO REMITTED <br /> vd <br />