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LIQUID WASTE PERMIT j <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION g <br /> 304 E.WEBER AVE.,3R°FLOOR,STOCKTON,CA 45202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT ERPIRF,51 YEAR FROM DATE ISSUED , <br /> JOB ADDRESS ( �+ <br /> CITYIZIP PARCEL SIZEJAPN <br /> OWNER NAME V7 ADDRESS u(17, <br /> CITYIZIP PHONE / <br /> CONTRACTOR Nei[:O� Igr+G�QY50%-I s' ADDRESS <br /> LodCITYIZIP L d[ PHONE �I .36 7-3 <br /> 0 <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNS HIP RANGE--SECTION <br /> i ` r i <br /> FERC TESTIS) I OW MANY '"1 APPLICATION#: 'C07-SS <br /> TYPE OF SEPTIC WORK:: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIA'L ❑OTHER , <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ;I NUMBER OF EMPLOYEES:- <br /> CHARACTER <br /> MPLOYEES:CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> 'y I <br /> [ ❑SEPTIC TANKIGREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 'i <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> j ❑LEACHING LINE NUMBER&LENGTH OF LINES I INFILTRATOR CHAMBERS <br /> I <br /> I� DISTANCE TO NEAREST: WELL FOUNDATION DROPERTY LINE <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 /> I ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION 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 PONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCE ATE WS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. ! <br /> SIGNED: `� 0. 1(1 TITLE: 1 DATE: �� '0 <br /> I <br /> r � b, 1IG t•P <br /> �I G <br /> � <br /> �' N M <br /> -� <br /> �r <br /> Ij � a <br /> .r <br /> i <br /> S. <br /> I� <br /> _ - _ ''� r� � •IR a. �c+�-s..sE '- �c�-4 ice-4.�• _ ._z rs �+�v�fyJ <br /> FOR DEPARTMENT USE ONLY 1`` <br /> APPLICATION ACCEPTED BY: li DATE:_ , <br /> TANK,PIT,OR SUMP INSPECTED BY: yy DATE: <br /> FINAL INSPECTION BY: li <br /> COMMENTS: E d 2 _ f <br /> k PE CODE SC AMOUNT CHEC RECEIVED BY DATE PERMITIS"RVICE REQUEST# SEPTIC IW <br /> INFO RE ED CASH I� <br /> Z� 5� 81�► L6 �q n 10 Qp 2-S-080 <br /> f9 "' oo <br />