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LIQUID WASTE PER" TT <br /> fAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONN,.WAL HEALTH DIVISION <br /> 304 E.WEBER AVE 3v'FLOOR STOCKTON.CA 95202(209)"H-3420 <br /> /U�' NON-REFUNDAB P/E�RMIT EXPIRES I YEAR FROM <br /> jDATE ISSUED may/ �] <br /> JOB ADDRESS 1I 5 1/�V 1lY ��'^C� \� APN 1 o J'131�"1 L�D � 1(] PARCEL SIZE:/_ � <br /> CITY/ZIP �-,\ _ �.�`'(c BUILDING(PPEEERMIT N IJ `Cc) I (7 o I ` <br /> OWNERNAME ::R Lo b1I,Q.\r Q� rp ADDRESS 07- / /,,2J J�]A 41 Tw.e � <br /> CITY/ZIP \ V�F�±O�\ jq c� PHONE NUMMElE"""-R C�1YJ J �/-^y"'1ni:3 1 /(�y <br /> CONTRACTOR n�eIRn ADDRESS �� ppJQQ// 1 /1C 1 1 l) G / <br /> CITY/ZIP 1 - 3 PHONE NUMBER (�O O <br /> GEOGRAPHICAL INFORMATION: COORDINATES: X Y TOWNSHIP RANGE SECTION 1 <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> )k NEW INSTALLATION 0, RESIDENCE NUMBER OF BEDROOMS: <br /> ❑ REPAHUADDITION ❑ COMMERCIAL <br /> ❑ DESTRUCTION ❑ OTHER <br /> NUMBER OF EMPLOYEES: <br /> ❑ ENGINEERED/ALTERNATIVE <br /> CHARACTER OF SOIL TO DEPTH OF 31: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> ❑ PERC TESTS) HOW MANY APPLICATION# �7 <br /> SEPTIC TANK TYPE/MFGT;t CO pg�Ane L <br /> CAPACITY E O #OF COMPARTMENTS 2— <br /> ❑ GREASETRAP TYPE/MFG CAPACITY #OF COMPARTMENTS <br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL 1 FOUNDATION PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINE #OF EINES: Z LENGTH OF LINES: DLSTANCETONEARM: WELLAI-0 FOUNDATION PROPERTY LINE <br /> INFLITRATOR CHAMBERS: <br /> ❑ FILTER BED WIDTH LENGTH DEPTH OPWANCETONEAREW: WELL FOUNDATION PROPERTY LINE <br /> ❑ MOUNDED WIDTH LENGTH - DEPTH DISTANCETONF,A M: WELL FOUNDATION PROPERTY LINE <br /> ❑ SUMPS WIDTH LENGTH DEPTH_ DISANCETONEARVs: WELL FOUNDATION PROPERTY LINE 4 <br /> ❑yI DISPOSAL PONDS WIDTH LENGTH DEPTH DIWANCETONEAREST: WELL FOUNDATION PROPERTY LINE �J <br /> SEEPAGE PITS It DIAMETER-'va- DEPTH DISFANCETONEAREST: WELLIM FOUNDATION PROPERTY LINE <br /> v <br /> I HEREBY CERTIFY THAT 1 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 /> MI IMU 2 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS EASE CALL-209)068$423 <br /> SIGNED: TITLE: G�� DATE: <br /> J <br /> Tc r-I <br /> FS I v,n, �Ta OF ,Hfid <br /> : <br /> i <br /> DEPARTMENT E LY <br /> APPLICATION ACCEPTED By An O EA V//� <br /> EMPLOYEE IDp DISTRICT OCATION <br /> INSPECTED BYI DATE ✓ PERMIT FINAL YES DATEF+(//r I1J✓ INSPECTOR: <br /> COMMENTS: 'LJ� <br /> PE CODE SC INFO AMOUNT CHECK/CASH RECEIVED DATE I PERMITSERVICE REQUESTF INVOICEN SEPTR➢DE <br /> REMITTED BY <br /> L <br /> Y7 3 U 15 00 Z 3371 1 <br /> REVISED RIFEI <br />