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JOB <br />CITYIZIP <br />OWNER NA <br />CITYlZIP <br />( I LIQUID WASTE PERMIT(-') <br />SAN JOAQ.,_. COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL hrrM;TH.DiVISION <br />304 E. WEBER AVE., 3RD FLOOR, STOCKTON, CA 95202 (209)468-34,20.._ '. I ; .. r' •, f; - s ,M <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED7-7 ' S <br />l PARCEL SIZFJAPN <br />CONTRALTO ADDRESS <br />CITYM PHONE <br />GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE__SECTION <br />PERC TEST(S) ( ) HOW MANY APPLICATION #: <br />TYPE OF SEPTIC WORK:NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERICIALOTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLO/Y�EES <br />CHARACTER OF SOIL TO A DEPTH OF 3 FEET: P /SUMP SOIL CHARACT R: d"yI1VATER TABLE DEPTH <br />❑ SEPTIC TANK/GREASE TRAP TYPE/MFG AC1TY NUMBER COMPARTMENTS <br />❑ PKG TREATMENT PLANT 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 � / 40 — INFILTRATOR C • <br />NA BES �y <br />DISTANCE TO NEAREST: WELL jrrWFOUNbAT10N PROPERTY LINE 6 YY�E <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 />a ' <br />SEEPAGE PITS WIDTH � <br />LENGTH r DEPTH �^ � <br />/�,]Jj f h <br />-Y DISTANCE TO NEAREST: WELL �[(" QUNDATION - -ALJ 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 CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDIANCES, STATE LAWS, ANI; RULES AND Rrl)ULAtIONS OF SAN JOAQUIN COUNTY. (y .1 <br />APPLICATION ACCEPTED BY: <br />TANK, PIT, OR SUMP INSPECPEI) BY: <br />FINAL INSPECTION BY: <br />FOR <br />v <br />USE <br />� nA-Pl:• f'/ -'J7— 0 <br />a%`, <br />PE CODE SCAMOUNT <br />INFO RtXOFITTED <br />` I V o <br />RECEIVED BY <br />'7 SII <br />6XSK <br />DATE <br />PERMTTISERVICE REQUEST # <br />OW Lf Le b <br />SEPTIC 1130 <br />I ~ <br />