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va <br /> LIQUID WASTE PERMIT ••�+" <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I ` <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> r <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> I ILA t A CSA �-ice P,( a ?qCn St— �r�� ��� <br /> JOB ADDRESS // 160 <br /> to �Q7� <br /> PARCEL SIZE/APN <br /> CITY/ZIP <br /> �� NAME ADDRESS ��� '��3 643-3,2'N <br /> � ���� <br /> Ti� 102 77 CJ "� <br /> CITY/ZIP PHONE _ <br /> wlo v s h �^ ADDRESS ( "J������� <br /> CONTRACTOR <br /> CITY/ZIP ( (Jr�( l ` ( v PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP RANGE_SECTION <br /> PERC TEST(S) ( ) HOW MANY I APPLICATION#: <br /> TYPE OF SEPTIC WORK: 4_NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ` <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL OTHER 3 VOG ` <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 COMPPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY EMhYNA(-I\1 1 <br /> ❑LIFT STATION SIZE TYPEOFPUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) RECF!\/Er - <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS llM�! ; r) I r <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE �r `IJ' <br /> 3AN JOAUUIN COUNT( <br /> ❑FILTER BED WIDTH LENGTH DEPTH ��PPpU��BrrLItC HEALTH SERVICES <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERT1lll f{�EIFAI TN pIVIS10A: <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 /> ❑SUMPS 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 /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCF,S f(TATF LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. �� ,� <br /> SIGNED �, TITLE:( .y�kCi���7 DATE:3::fi k- <br /> V <br /> I 1A IA <br /> cm <br /> �1 <br /> n <br /> \ V <br /> s <br /> /,, FFq� DE P I ENT USE ONLY '/<� <br /> APPLICATION ACCEPTED BY: W-- DATE: N3 <br /> TANK,PIT,OR SUMP INSPECTED BY: -DATE:- <br /> FINAL <br /> ATE:FINALI 110 BY` !� <br /> COMMES: Q q/& E" �p l �7 '� <br /> � IG <br /> PE CODE SC AMOUNT CHECK X/ RECEIVED BY DATE PERMIT'E 'ICE Q -ST# SEPTIC IDA <br /> INFO RFMITTED CASH G� <br /> ' J <br />