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f <br /> LIQUTT) WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBL LTH SERVICES ENVIRONMENTAL HEALTH DIVi�qN <br /> 304 E � 02 WEBER AVE.,3aOR,STOCKTON.CA 952 (209 )468-3420 G <br /> A NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED R E Q U E S Ta' <br /> JOB ADDRESS ( : I I I , -' F C) <br /> CITY2IP ! i I ''J PARCELSTZ&APN !tel I `\ I ,� - )(.` <br /> z OWNER NAME I . � '•+ - I`': 1- ADDRESS 1 i t. 1 T +' <br /> PHONE <br /> CONTRACTOR „I P. 1 [ YAC 1's 1.^I L� 7 i ;'-// ADDRESS I? L <br /> CITY/ZIP !%(r !1 f PHONE ”,17 <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP_RANGE_SECIION <br /> PERC TEST(S)('Vf HOW MANY I APPLICATION k I 1.4 —q7 I,(U <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: vp RESIDENCE ElCOMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS I NUMBER OF EMPLOYEES:_ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANKJGREASE TRAP TYP&MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: W ELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEN; <br /> •a ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION -ROPERTY LINE­R4MENT <br /> ❑FILTER BED WIDTH LENGTH DEPTH RECEIVED <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE �b O 2 01 <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE SAN Ln Ani IN COUNTY <br /> 10 SEEPAGE HEALTH SERVICES <br /> SEEPAGE PITS WIDTH LENGTH DEPTH ENVIRONMENTAL HEALTH DMS04 j <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH t <br /> t <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 <br /> ORD IANC.C/' ATE LAWS.AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: !f CC 0—I—t -- TITLE:( �( �1 '•r DATE: V r 1 <br /> Al <br /> i' L It <br /> i t <br /> I � <br /> ../� FONt)urr�pARTM: USE ONLY <br /> APPLICATION ACCEPTED BY: ' <br /> e !/ �4 6,���/ DATE: <br /> D <br /> TANK PIT.OR SUMP INSPECTEBY 7 DATE: <br /> FINAL INSPECTION BY: <br /> �COMMENTS. <br /> _ PE CODE SC AMOUNT CHECK RECEIVED BY DATE PERMIT/SERVICE REQUEST 0 SEPTIC ID/ <br /> INFO Re7NRTED CASH <br /> I <br />