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\ '� LIQUID WASTE PERMIT <br /> SAN A" IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIV <br /> Lebo <br /> AQ Q I-S E.WEBER AVE.,3 R FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> lY(1����VJ-_ CJOC� NON-REFUNDAB E PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> C nPARCEL SO <br /> CITY/ZIP IZE/APN L� 4 <br /> OWNER NAME ADDRESS • D <br /> CITY/LIP O PHONE --- <br /> ~ CONTRACTOR ADDRESS <br /> CITY/ZIP PHONE_y, <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP_RANGE_SEj�`TION <br /> PERC TEST(S)( )HOW MANY APPLICATION M: <br /> TYPE OF SEPTIC WORK: ❑�RNSTLLATION REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑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 SOILyyCCPJJIJ�ARRACTER: D WATER TABLEPI'H_. <br /> ❑SEPTIC TANK/GREASE TRAP TYPFIMFG CAPACITY/-Re "BER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL/ -/-FOUNDATION PROPERTY LINE v ENBD <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES j__J O ` INFILTRATOR CHAMBERSI <br /> DISTANCE TO NEAREST: WELL i�n`4GUN,DATION��PROPERTY 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 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,AND RUJ%.E9/�1ND REGULA IONS F SAN JOAQUIN COUNTY. h <br /> SIGNED: TITLE, DATE: V <br /> F� a <br /> W d <br /> L <br /> SA J AU IN <br /> _41i B61C 44 <br /> F VIR NM NT HE !T DIV 510" <br /> y FOR DEPARTMENT USE ONLY (J� <br /> APPLICATION ACCEPTED BY: DAA p 0 G ZI <br /> TANK,PIT,OR SUMP INSPECTED BY: Ate' <br /> low FINAL INSPECTION BY: A Z`_��O' <br /> PECODE SC AMOUNTC RECEIVED BY DATE PERMIT/SERVICE REQUEST M SEPTIC IDN <br /> INFO REMITTED CASH ----- <br /> n. f s 9 0 8 5 2� <br /> IIIA <br />