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LIQUID <br /> JOAQUIN COU V iL WASTE E r LLIC HEALTH SERVICES ENVIRONMENTAL <br /> l MI <br /> HEALTH DIVISION <br /> 303 F.WEBER AVE..3R°FLOOR.STOCKTON.CA 95202 (209)4W3420 <br /> `ION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CIIYILIP - YARCELSIZEfAPN <br /> OWNER NAME ADDRESS <br /> CITY/ZIP PHONE <br /> CONTRACTOR ADDRESS – <br /> CITY(ZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTFS: X Y TOWNSHH'_RANGE_SECTION_ <br /> PERC TEST(S) ( ) HOW MANY APPLICATION N: <br /> TYPE OF SEPTIC WORK: Ll NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE 'PRESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:—_ NUMBER OFEMPLOYEES:_ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH_ <br /> ❑SEPTIC TANKIGREASE TRAP TYPEIMFC CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PRO TREATMENT PLANT DISTANCE TO NEAREST: WELL ' FOUNDATION PROPERTYLINE <br /> ❑LIFT STATION SIZE TYPEOFPUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Q LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION' PROPERTY LINE. <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL FOUNDATION: PROPERTY LINPA*Pv+E 1\, <br /> El MOUNDED WIDTH LENGTH DEPTH RECEI` ; <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> i � 4 ,,. I <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH �'• •�j <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY94PoE �UNI� <br /> PUBLIC H�:;_Ihi HW)CES <br /> ❑SUMPS WIDTH LENGTH DEPTH ENVIHONMENTAI HFAITH OMSIC., <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 /> SIGNEU: <br /> TITLE_' DATE: <br /> t- - ---------- ------- <br /> r' <br /> ------------- <br />