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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVI N <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 �' H R 3-,](D FI CD <br /> i NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FCa R /-\L.L <br /> 1L <br /> JOB ADDRESS 0 /�S /� o��' 1 -7 2 <br /> CITY/ZI1) ��� C'4 1 Z4o PARCEL SIZE/APN `© A-C <br /> OWNER NAME-YC-CIC,IC KA'1 nZAC1h'N ADDRESS d- S� ?/X,e� 1 7230 �{ <br /> CITY/Zip/.IJm2�cN PHONE (�` -937 - <br /> CONTRACTOR )_:A N � 1�IC)✓� (� ADDRESS 'C-v{�,J(f e�� w <br /> CITY/Zll' ZvJ L._ `5�1 PHONE /4.-G&I 1�+� <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP 3 RANGE C—SECTION_ <br /> PERC TEST(S) (vT HOW MANY 4LO APPLICATION#: <br /> T <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: I <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET:I OA N\, PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH 1 <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE-- <br /> • <br /> INE _❑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 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 /> Immom <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH Soho <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 /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: TITLE:�� V,�- Cr�1fC! DATE: <br /> LN <br /> Q <br /> 1 <br /> -r <br /> UD JC EA TH EF ICY 5 <br /> rrAl HE IT I)I ISk /(D <br /> � \�pR DEPAR'r LENT US'0 1 Y /7 <br /> APPLICATION ACCEPTED BY: v` - DAT L <br /> DATE:_ <br /> TANK,PIT,OR SUMP INSPECTED BY: <br /> FINAL INSPECTION BY:� -C�f <br /> COMMENTS: <br /> PECODE SC AMOUNT1E / RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC IDN <br /> INFO REMITTED CASH <br />