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E_ LIQUID WASTEPERMi I 2-4- FIR N®—Fl <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> Ifi _r <br /> 304 E.W@BER AVE.,31D FLOOR,STOCKTON,CA 95202 (209)468-3420 R E Q U E A <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED F--C)R /-\L--L <br /> yy fmoi'SPEC --n(:7" <br /> JOB ADDRESS i <br /> ij"a � O <br /> , <br /> CITYIZIP 1 f1 a 4n^rt Ccs �� `� +� b PARCEL SIZFJAPN1 ] L <br /> OWNER NAME-j /- f -.---ADDRESS_ <br /> CITY/ZIP a- f^ ` 'I ° �' PHONE 2 +• ~ <br /> CONTRACTOR ADDRESS j <br /> CITYPZIP . 1 " r PHONE <br /> GEOGRAPHICAL INFORMATION: COORDiANTES: X Y TOWNSHIPRANGE_SECTION <br /> PERE TEST(S) { ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION X�,'DF6TRUCTION <br /> INSTALLATION WILL SERVE: ❑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 TANKIGREASE TRAP TYPEIMFG CAPACITY NUMBER OP 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 I INFILTRATOR CHAMBERS <br /> AYIVlEry r <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPir[tTY LI>� <br /> E3 FILTER BED WIDTH LENGTH DEPTH <br /> i DISTANCETO NEAREST: WELL FOUNDATION: PROTfRTw <br /> ❑MOUNDED WIDTH LENGTH DEPTH SAN JOAOulyd <br /> OUNTv <br /> . DISTANCE TO NEAREST: WELL FOUNDATION PROP RTR61Ti(�� CFS <br /> NWRONMFNTAI_HFAIT:-+nlVlsiiii' <br /> 1.0 SEEPAGE PITS WIDTH LENGTH DEPTH <br />+ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> If ❑SUMPS WIDTH LENGTH DEPTH <br />± DISTANCE TO NEAREST: WELL FOUNDATION PROPF*TY 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 /> s <br />++ ORDIANCES ATE LAW' AND AND GULATIONS OF SARI JOAQUIN COUNTY. <br /> i SIGNED: TITLE: DATE: <br /> V <br /> 1 <br /> f <br /> f <br /> h <br />} <br /> (�,[. R DEPART T USE ONLY Jj VJ <br /> APPLICATION ACCEPTED BY: `r DATE: 7 1 <br /> TANK,PIT.OR SUMP INSP BY: ATE: q t <br /> FINAL INSPECTION BY: F� � r-...." C "���"—O • <br /> COMMENTS: <br />' PE CODE Sc AMOUNT CHECK Nf RECEIVED BY DATE PERMIT/SERVICE REQUEST N SEPTIC IDN <br /> INFO RrMI CASH <br /> ;� o o J ns a <br />