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LIQUID WASTE PERMIT _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIS16N` _►, { <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> ON-REFUNDABLE PERMIT EXPIRE'1 YEAR FROM DATE ISSUED <br /> �J�� GJ e._L <br /> JOB ADDRESS J l N S��"` L 15 Y 1� / / I � _�;—-^ 1 _ <br /> CITY/LIP �COy �.� PARCELSIZE/APN 005 - `U 1 -3(-/- 11' c' <br /> OWNERNAME t�OV �.r�bi ADDRESS R7 �YUPti Ppn to <br /> CITYIZIP r PHONE / 1«�\/ <br /> CONTRACTOR ` � ADDRESS � `' ` <br /> CITY2IP LJ6 CA' ( �� 1 (v 7-/ � C� PHONE( / <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <br /> PERC TEST(S)$.),HOW MANY ' APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <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 LINE <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 °ROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> 13 MOUNDED WIDTH LENGTH DEPTH PAYNIk-. <br /> RECEIV✓ _; <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH 1 20 <br /> 0 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ter`•J.PJ�1_;( <br /> 13 Sumps WIDTH LENGTH DEPTH PU[31 '114 f'CAJNTY IC HEALEN� I; <br /> �n,r���T,l , <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPER fVIrvG �' 'IT! ✓i. <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH v\ <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE \ <br /> 1 HEREBY CER IFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN , T EL ,AND ULES ANDEGULA IONSS O�F�SAN JOAQUIN COUNTY. <br /> SIGNED: •- c, f ✓• K TITLE:���`��dC�^J DATE: �y^✓`�U I lJ <br /> OrylSOS <br /> ri <br /> ?to ' <br /> M N aw <br /> Aaa <br /> F� T- '/� lM <br /> `11 <br /> �l ---_ <br /> t. --- ----- .�— ---- -- —Ll <br /> la <br /> APPLICATION ACCEPTED BY: DATE: ` <br /> TANK,PIT,OR SUMP INSPECTED BY, DATE: CJ <br /> FINAL INSPECTION BY, <br /> COM EN'S- Azim <br /> ✓ - - d( <br /> PE CODE SC AMOUNT RECEIVED BY DATE PERMITISERVICE REQUEST# SEPTIC ION <br /> INFO REMI ASH <br />