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l� <br /> LIQUID WASTE PERMIrl <br /> SAN JOAQ N COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL_ ALTH DIVISION <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PER IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS -- � O kv , <br /> CITY/ZIPPA•RRCEL SSIZE/APN I, 4? _J �S / © J 4� <br /> OWNER NAME o J ADDRESS 2 J /`( 5,6tl n�J iJ�LaLM r <br /> CITY/ZIP C 2 1 PHONE l qj3 E_) Ll M_ -0571 <br /> CONTRACTOR f I C�-jy S ADDRESS QLD f40V'T t l-- <br /> CITY/ZIP W i `� " PHONE / -� 3,_ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP4 <br /> WANGE7_. SECTIONS <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: 1�NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: Okf2ESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: Z NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �) 1 <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPPff._ C <br /> ❑SEPTIC TANK/GREASE TRAP TYPEIMFG 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(ENCLOSEM <br /> OF LINES / INFILTRATOR CHfM <br /> ❑LEACHING LINE NUMBER&LENGTH <br /> L u U r Y <br /> DISTANCE TO NEAREST: WELL FOUNDATION °ROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <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 /> ORDIANCES,STAT AWS, RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. ' ! / <br /> SIGNED: TITLE: � h`"7l� DATE: O d� <br /> 1 <br /> CIO 191 <br /> 1 <br /> 1 - <br /> 1 <br /> 1 <br /> 1 <br /> 1 <br /> 1 <br /> 1 <br /> N ^� NO CHEMICAL <br /> 1 <br /> • FO UEP RTD1E USF:ONLY <br /> S-JA . 30, F-,903 <br /> APPLICATION ACCEPTED BY: DATE: u,N.7� <br /> TANK,PIT,OR SUMP INSPE Y: DATE:_ <br /> FINAL INSPECTION B �� <br /> COMMENTS: <br /> PE CODE SC AMOUNT CK#/ RECEIVED BY DATE PERMIT/SERV ICE REQUEST# SEPTIC ID# <br /> INFO REMITTED <br /> 14,222 5zl 04 "Z if- CO3a� <br />