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i <br /> LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUJILIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE 3RD FLOOR,STOCKTON.CA 95202(209)4DR_3420 <br /> Li NON-REFUNDABLE PERMIT EXPIRES 1 YEARFROM DATEISSUED , <br /> JOB ADDRESS J((��/rf fCi rexl J] �I,�r �Xo - APN �7,'340 V 1 PARCEL SIZE:. wJ �,� <br /> CITYIZIP J IL' A Ljq I. BUILDING PERMITk • <br /> OWNERNAME I � ADDRESS ! <br /> CITYIZIP 11 f 1 P j y/�I� /i�/t *'9d :404 'C'•`'�7 PHONE NUMBER "f" ) I I'.Z <br /> tl <br /> CONTRACTOR <br /> or IO'n w ADDRESS I <br /> ,/ <br /> CITY/ZIP ✓ `�R•k r�/" ���dA:/ SI/'�L��f: L:f 5 PHONE.NUMBER R U r 'f G_J� .S ! <br /> GEOGRAPHICAL INFORMATION: COORDINATES:X_- Y.. ._.__TOWNSHIP RANGE SECTION <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS-_2 <br /> Cl NEW INSTALLATION ❑ RESIDENCE NUMBER OF BEDROOMS: <br /> ❑ REPAIRIADDITION ❑ COMMERCIAL <br /> 13 DESTRUCTION ( OTHER f rJWT 1P mG trl 4tNUMBER OF EMPLOYEES: <br /> ❑ ENGINEERED/ALTERNATIVE / It �UF rC <br /> CHARACTER OF SOIL TO DEPTH OF 3': I(L�..;J= PITISUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> — <br /> E) PERC TEST(s) HOW MANY APPLICATION# <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY #OF COMPARTMENTS <br /> ❑ PKGFXPLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> ❑ LIFT STATION SIZE TYPEOFPUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1 <br /> ❑ LEACH LINE #OF LINES: LENGTH OF LINES: DM—CE TONEAREST: WELL FOUNDATION PROPERTY LINE <br /> V <br /> INFLITRATOR CHAMBERS: r <br /> ❑ FILTER BED WIDTH LENGTH DEPTH DISrAN[E rON[ARBR: WELL FOUNDATION PROPERTY UNE <br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCE TOxEAacti-r: WELL FOUNDATION PROPERTY LINE <br /> ❑ SUMPS WIDTH LENGTH DEPTH DISTANCETONEA110T: WELL FOUNDATION PROPERTY UNE T I <br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH DE4TANCE TO NEARECT: WELL FOUNDATION PROPERTY LINE <br /> ❑ SEEPAGE PITS # DIAMETER DEPTHr' oISFkNCE To HEARER: WELL ,!I^' FOUNDATION PROPERTY LINE <br /> s <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)463-423 <br /> SIGNED: 7' TITLE: •i'�_.. DATE: /: <br /> _ <br /> `- <br /> - <br /> _ - <br /> _ <br /> lo <br /> : <br /> vim A ± <br /> -- �IBt <br /> LIC HE LT - <br /> - _ <br /> t' DEPARTMENT ��n.EA <br /> r/•IAPPLICATION ACCEPTED BY:� f��f DATE:��_ w EMPLOYEE ID# ISIRICT_1Z,LOCATION /«/ <br /> INSPECTED BY�: •' /DATE:-n,. PERMIT FINAL❑ YES DATE / INSPECTOR: <br /> COMMENTS: i'� O FIAA OIT."M,./) .�y71STd(C+'P AFrIS :M_�If(:/VQ�,tm_o !GAS' I'1 <br /> J ' • <br /> PECODE SC INFO AMOUNT snN ,',P/CASH RECEIVED DATE PERMITBERVICE REOUESTq INVOICE!, SEMIC IDk <br /> REMITTED BY <br /> Z l 5 2 a .5(1 c9v3 J %'vC/ `19q�3 <br /> RE VISEP E-I.AAI - - - <br />