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LIQUID WASTE PERMITF-A <br /> SAN 70AQLJLN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL__-'ALTH DIVJSIOI� y } <br /> 304 E.WEBER AVE.,3A0 FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-RFFUNDAB E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED� <br /> J <br /> 3 <br /> v�'�1� C?') ws W � t'h s I <br /> JOB ADDRESS <br /> CITY/ZIP �A�c.�c PARCELSIZFIAPN 4` � L' n �sK-I O� ' L(�` w` <br /> OWNER NAME_` 1 l '�,� DDRESS <br /> PHONE <br /> CITY/ZIP �Q � <br /> CONTRACTOR I D' r j CyY bV � <br /> ADDRESS <br /> CITYIZIP ��t + PHONE_ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y <br /> TO W NSHIP_�IANGESE�MONL�- <br /> 0 <br /> , <br /> PERC TEST(S) ..)HOW MANY -_ APPLICATION <br /> NEW INSTALLATION ❑ <br /> REPAIR/ADDITION DESTRUCTION r J <br /> TYPE OF SEPTIC WORK: `J <br /> INSTALLATION WILL SERVE: ❑RESIDENCE <br /> ❑COMMERICIAL ❑OTHER <br /> NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES <br /> k NUMBER OF LIVING UNITS:- PIT/SUMP SOIL CHARACTER: WATER TABLE DEP'T'H <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: <br />! ❑SEPTIC TANK/GItEASE TRAP TYPE/MFG <br /> CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL <br /> FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP - SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES ! INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL <br /> FOUNDATION PROPERTY 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 /> ElSEEPAGE PETS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> I DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY C TIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIA AT- AWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> S[GNE TITLE:1560 f�I{�� -DATE:__ `� o. <br /> V <br /> e <br /> t <br /> -i <br /> e <br /> � I <br /> to <br /> +� L <br /> n'141 <br /> S <br /> NJ l�; U'tN CU NI) <br /> I i a I illi <br /> I <br /> FOR DEP MENT USE ONLY �. <br /> DATE: <br /> APPLICATION ACCEPTED BY', lJl 3- <br /> O . <br /> I <br /> I TANKPIT OR SUMP INSPECTED BY: - DATE.. <br /> , <br /> wN BY: <br /> PIS <br /> LCOMMENT'i�SC AMOUNT C #! RECEIVED BY DATE PERMITISERVICE REQUEST# SEPTIC ID# <br /> fNFO REMLiu <br /> ITT ASH <br /> -I 7-- 4qo,�)5 an ra�aCaLq <br />