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( LIQUID WAS! 2ERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVJ�IU4 HR N c)-T l C <br /> 304 E.WEBER AVE.3'D FLOOR.STOCKTON.CA 95202 (209)468.3420 <br /> R ECRU 6.�:.S,TEi7 <br /> N FUy AiLI FGP ALL <br /> JOB ADDRESS ` O I! <br /> CITY/71P_ /�Fl `. PARCELSIWAPN <br /> OWNER NAME�j ft 1,1 Iv i f7,q, ;4,i&I c_ ADDRESS f 114: <br /> CITYIZIP - <br /> CONTRACTOR 1"t; ny) cry I �l �� <br /> iii CITYa4PII ! '—(r I" �o�r f/ PHONE_ I <br /> f GEOGRAPHICALINTORMATION:COORDIANTES: X Y TOWNSHIP---_RANGE---SECTTON <br /> i <br /> PERC TEST(S)( )HOW MANY L APPLICATION 0: <br /> -J TYPEOF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIPJADDrnON ❑ DFSTAUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE O COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBEROFBEDROOMS: NUMBEROFEMPLOYEES:_ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> E3 SEPTIC TANKM,REASETRAP TYPFIMFG CAPACITY NUMBER OF COMPARTMENTS— <br /> C3 PKc TREATMENT PLANT <br /> OMPARTMENTS❑PKGTREATMENTPLANT DISTANCE TO NEAREST. WELL FOUNDATION PROPERTY LINE <br /> Q LIFT STATION SME TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LPACHING LINE NUMBER R LENGTH OF LINES INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE - <br /> 13 FILTER BED WIDTH LENGTH DEPTH .. <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> '.S DISTANCE TO NEAREST: WELL FOUNDATION^ PROPERTYLINE—PAYMENT <br /> 13 SEEPAGE PITS WIDTH L.ENGTTI DEPTH RECEIVED <br /> f i <br /> DISTANCE TO NEAREST. WELL FOUNDATION PROPERTY LINE q <br /> 13 Sumps WIDTH LENGTH DEPTH NOV S 2000 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UINCOUNTY <br /> ❑DISPOSAL PONDS WIDTH— LENGTH DEPTH P EALTHSERYGES <br /> / SAL HEALTH Dmsl , <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THE WORK WELL BE DONE IN ACCORDANCEOVITH SAN JOAQUIN COUNTY <br /> ORDIANCES,$TATE LAWS,AND RULES AND REGULATIONS OKSAN JOAQUIN COUNTY.. - <br /> /f,f; n I�U <br /> SIGNED: !,� ,--„ 'F[TLE:� �I r 1 ` _ DATE:,�.� •C`t�i <br /> a. I [Mill' I I <br /> I . <br /> 1 <br /> s l a I I <br /> a <br /> I >� <br /> PFT— <br /> I I I <br /> I <br /> pot <br /> + I I <br /> I I <br /> 1 � I I I <br /> { I <br /> I I =7 I I I <br /> I I 1 1 1 1 1 1 I I I I I I —1-1hoI I I I l k ! <br /> CC�� FOR DEPARTMENT USE ONLY C`/'/-�;1./ 1 CI <br /> iii APPUCA71ON ACCEPTED BY'. I'� IALt DATE: ' 1S <br /> TANK PIT.OR SUMP INSPECTED BY: DATE' <br /> { FINAL INSPECI'ICN BY' <br /> I COMMENTS: <br /> DECODE SC AMOUNT 9 CHECKS RECEIVEDBY DATE PERM71SERVICEREQUEST4 SEPTIC LD- <br /> INFO <br /> MINFO ItimmTED 1 <br /> Ir <br /> I'^ <br />