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LIQUID WASTE PERMIT`.: <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVECES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,31D FLOOR,STOCKTON,CA 95202 (209)468-3420; ' <br /> �T {{ NON-REFFUNDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOTS ADDRESS 1 ! [ . � C? Cr�!J LA Ckw Vl r <br /> r r'� ! <br /> CITY/ZIP L PARCEL SIZFJAPN (r}t .? L V'f� f ( �(j <br /> OWNER NAME FYn\�� l*g f S ADDRESS 1 , W ibt `-h �`� <br /> CITYIZIP 'l-AtX:0t PHONE _ <br /> CONTRACTORtADDRESSCJ�I _ <br /> I CiTY(LIP PHONE <br /> GE\OG�} HICAL�INFORMAT ON• COORDIANTES: X Y TOWNSHIP RANGE SECTION <br /> PERC T STG)i(�OWN VKTe� APPLICATION#; <br /> C TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION D DESTRUCTION <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: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> 1 ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> -YMEEV' <br /> 13LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) R E CF I V E _ <br /> ❑LEACHING L[NE NUMBER&LENGTH OF LINES ! INFILTRATOR CHAMBERS y � <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE AUG1 <br /> 01 <br /> 0 FILTER BED WIDTH LENGTH DEPTH SAN JOAOLJI 1 COUNTY <br /> PUBLIC HEALTH STEWIC[S <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY Ll�*�Ir4OUMENTAL IIL:AI TH `M'I kY,l <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 /> Cl SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION .PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH t <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE C <br /> I HEREBY RTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORAIA E S TE LAWS,AND ULES AN RE ULATIONS OF SAN J AQUIN COUNTY. ` <br /> SIGNE a� r TITLE: 1��7 DATE: <br /> r <br /> .rte <br /> `M <br /> extic <br /> m CA <br /> (21 <br /> h <br /> r>j 11 <br /> All- <br /> FORD IPART ONLY h <br /> APPLICATION ACCEPTED BY. - all - -DATE: V�•) � "•' ` <br /> 3 TANK,PIT.OR SUMP INSPECTED BY: DATE: <br /> r FINAL INSPECTION BY: <br /> I COMMENTS: <br /> ,, <br /> PE CODE SC AMOUNT CHECK M! RE EIVEDBY DATE PERMITlSERVICEREQUEST# SE Inx <br /> INFO REMITTE <br /> a � �� - `� <br />