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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION L <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> 2 h' C ANON-REFUNDABLE PERMIT EXPIRESSII YEAR FROM DATE ISSUED / <br /> JOB ADDRESS t` `V' l�S )�`� P�1` l`I C]S�J1nin 10(e j�C.>' <br /> CITY PARCEL <br /> LSMSI•LE/APN C� •�GQ <br /> NAME ADDRESS 62 -,)t- IW I <br /> CITY/ZIP PHONE J c, (? L p ?� <br /> v ` _ <br /> CONTRACTOR t2 h �^ ADDRESS�`� <br /> CITY/ZIP_ (Lr�t r (" 0- d PHONE_ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGESECTION <br /> PERC TEST(S) ( ) HOW MANY I - APPLICATION#: <br /> TYPE OF SEPTIC WORK: 4-NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION i <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL _Xk-0THER Scy oc, <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: 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 L714EY Ate_; <br /> ❑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 'AN JUAv(JIf'1 LI)UN f <br /> PUBIIc lif iluw;(: <br /> RVIC(f <br /> ADISTANCETO NEAREST: WELL FOUNDATION: PROIL� �I ial A1111�I',rit <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUhIPS 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 I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY A_f) <br /> ORDIANC' TAT' A WS,11AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. �.yy►� j��' \� <br /> SIGNEDQ, -TITLE: DATE: <br /> DATE: V <br /> V 1 <br /> 4. <br /> �• <br /> ` V <br /> 1 <br /> 5 <br /> w <br /> f <br /> is <br /> OF, DEP ENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE:-2- 6 OL- <br /> TANK, <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE: <br /> FINAL I�7r P I BY" <br /> COMMENTS: 97 <br /> PE CODE I SC AMOUNT CHECK#/ RECEIVED BY DATE PERMIT E ICE T# SEPTIC ID# <br /> INFO RCMTITED CASH <br /> J <br />