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LIQUID WASTE PER11P"T 3.3 C7
<br /> . JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMEI..,.L HEALTH DIVISION
<br /> 304 E.WEBER AVE 3N6 FLOOR,STOCKTON,CA 45202(209)469-3420
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<br /> NON-REFUNDABLE PERMIT EXPIRES i YF.ARR ROrlrbl AaTE�ISSCTED CPT r^r,,(�fJ/f��
<br /> JOB ADDRESS [74 I « 0 APN �a(1. l(J v 1f� ItY� M`f'�
<br /> CITY/ZIP � �1�. y y-} (.:f/T BUILDING PERMIT#
<br /> OWNER NAME ADDRESS
<br /> CITYIZIP ,� rko -,. I)' (tiN E� PHONE NUMBER ` O 66SO
<br /> CONTRACTOR ADDRESS
<br /> CITYIZIP PHONE NUMBER
<br /> GEOGRAPHICAL INFORMATION: COORDINATES: X Y TOWNSHIP RANGE SECTION
<br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS:
<br /> ❑ NEW INSTALLATION O RESIDENCE NUMBER OF BEDROOMS;
<br /> WEIIFNGINEERED/ALTERNATIVE EPA1R/ADDITION ❑ COMMERCIAL
<br /> LESTRUCTION C7 OTHER NUMBER OF EMPLOYEES:
<br /> CHARACTER OF SOIL TO DEPTH OF 3': PITISUMP SOIL CHARACTER: WATER TABLE DEPTHi:
<br />'I
<br /> ❑ PERC TEST(S) HOW MANY APPLICATION#
<br /> D SEPTICTANK TYPEIMFG CAPACITY #OF COMPARTMENTS
<br /> ❑ GREASE TRAP TYPE/MFG CAPACITY #OFCOMPARTMENTS
<br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE -
<br /> ❑ LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM)
<br /> ❑ LEACH LINE #OF LINES: LENGTH OF LINES: DISTANCE TO NEAREST: WELL FOUNDATION - PROPERTY.LINE �-
<br /> INFLITRATOR CHAMBERS:
<br /> ❑ FILTER BED WIDTH LENGTH DEPTH DISTANCE TO NEAR&CT: WELL FOUNDATION- PROPERTY LINE
<br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCE.TONEAREST': WELL FOUNDATION PROPERTY LINE
<br /> ❑ SUMPS WIDTH LENGTH DEPTH - DISTANCE TO NEAREST: WELL - FOUNDATION-' PROPERTY LINE
<br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH - DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> k ❑ -SEEPAGE PITS- # DIAMETER DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> HEREBY CERTIFY THAT 1 HAVE PREP E THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS
<br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY,
<br /> 1 U OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CA 4L(209)468-3423
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<br /> IGNED: > TITLE:l4 � � ATE:
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<br /> DEPART# USE ONLY
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<br /> N..r APPLICATION ACCEPTED BY: �1�'�-V AREA EMPLOYEE IDH T� D TRICT LOCATIONI
<br /> j INSPECTED
<br /> BY: DAT " PERMIT FlN7O YES DATE. C �I
<br /> COMMENTS: r
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<br /> PE CODE SC INFO AMOUNT CHEC C'A RECEIVED DATE PERM ITISERVICE REQUEST# INVOICE# SEPTIC IDN
<br /> REMITTED BY
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<br /> REVISED 9-i5.41
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