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LIQUID WASTE PERMIrr- <br /> SAN JOA N COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL,,. ALTH DIVISION s - <br /> 304 E.WEBER AVE.,3R°FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PFRMIT F,XPI ES I YEAR FROM DATE ISSUED P == ��L <br /> JOB ADDRESS M 8 F>E Cr }'//a��,r t \yl u' <br /> CITYlZIP PARCELSIZElAPN <br /> OWNER ADDRESS <br /> � <br /> CITY/ZIP 7 <br /> NAME PHONE X .�"�►� <br /> N240 <br /> • <br /> CONTRACTOR ADDRESS `•..R yv <br /> CITYIZIPi/ PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNS HIPRANGE__SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: C3 NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE; ❑RESIDENCE �COMMERICIAL C7 OTHER �^7� <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:-(00 <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEE PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) r 7 x s <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES 1 INFILTRATOR CHAMBERS ; {pCJ��� f <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE Sb OX, <br /> +++��` <br /> FILTER BED WIDTHLENGTH DEPTH '7Acyxy SF <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE z 12000 <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH PAYNl LIQ Sj I <br /> DISTANCE TO NEAREST: WELL FOUNDATION ��P3EM RIE-Y LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION 4P520PE�CY°tNE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH SAN J(�AOUIIV GOuJ' <br /> PUBLIC HEALTH SERVICES <br /> DISTANCE TO NEAREST: WELL FOUNDATION�^TTI�RiQP � I �IIIQN <br /> 1 HEREB CERTIFY TH HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIA JXLS ND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: TITLDATE: Z f <br /> - - - — - <br /> I <br /> i f _ <br /> f.. <br /> IM 1 <br /> ol 1 17,77 <br /> �FnJOR DEP T T USE ONLY <br /> APPLICATION ACCEPTED BY: bATE:,, j iI+SJ' <br /> TANK,PIT,OR SUMP INS F A DATE: <br /> FINAL INSPECTION BY: <br /> COMMENTS:' <br /> PECODE SC AMOUNT CHECK#! RECEIVED BY DATE PERMITISERVICE REQUEST# SEPTIC ID# <br /> INFO REMITTED CASH �f <br /> �J� ✓ O <br />