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r J <br /> , .,IQUID WASTE PERMIT <br /> SAN JOAQUIN304E WEBER AVE.,-3RD FLOOR,STOCKTON.CA ENVIRONMENTALNTY PUBLIC HEALTH SERVICES 5202468-3�IVISION <br /> NON-REFU 0ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (/` <br /> PARCEL SIZE/APN <br /> O <br /> CITY/ZIP <br /> OWNER NAME ���!1 �� Yt�-= ADDRESS <br /> I PHONE �/ <br /> CITYIZIP � A _ e <br /> CONTRACTOR . Y l ADDRESS TF h l <br /> CITY/ZIP (A1t ail PHONE _ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWN IP - RAN E <br /> PERC TEST(S) ( OW MANY-.�. APPLICATIO(yM: <br /> TYPE OF SE11I1C WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION \ ❑ DESTRUCTION N <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 J <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE- <br /> C]LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) Z <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION °ROPERTY LINE <br /> Cl FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> Cl MOUNDED WID'I'II LENGTH- DEPTH <br /> DISTANCE TO NEAREST: WELL. FOUNDATION PROPERTY I.INI:_ T` <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH I <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCI-TO NEAREST: WELL FOUNDATION PROPERTY LINK <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 WIL4 BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANC' ATEJAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. / <br /> SIGNED: P➢➢I TITLE:�l�L!/D�Iki� DATE: <br /> t _ ------------- <br /> ! <br /> ➢ D <br /> I I <br /> 6 I� <br /> PIN <br /> e w <br /> I 1 <br /> I I \0 <br /> I <br /> — — <br /> APPLICATION ACCEPTED BY:, �� -r'� �� DATE: <br /> TANK.PIT.OR SUMP INSPECT BY: DATE: <br /> FINAL INSPECTION BY: � <br /> COMMENTS: <br /> PECODE SC AMOUNT 4CHECK RECEIVED BY DATE PERMIT/SERVICE REQUEST N SEPTIC IDN <br /> INFO REMITTED CASH <br />