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LIQUID WASTE PERMI A� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> ! 304 E.WEBER AVE.,3"'FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> 24 HR NC) <br /> (' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED REG)U ESTE <br /> JOB ADDRIESS �^' ✓ l��^� A_' /J <br /> CITYlZIP Ii 5/ G S24 S PARCEL SIZFlAPN �'! C;TI O N S <br /> OWNERN�AME�+/� 7'Aor7� I�d Vex, ADDRESS ADDRESS �+�X 7 �2U <br /> CITYrzIP 5m C'IO1/ /v - --- PHONE 7 <br /> I <br /> CONTRACTOR ADDRESS <br /> ' I <br /> CLTYlZ1P <br /> PHONE �s <br /> I <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGESECTION <br /> FERC TEST(S) ( ) HOW MANY APPLICATION#; <br /> it I <br /> I I <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION Q)eESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> I I <br /> NUMBER`OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> I I <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TALE <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPART <br /> i <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LIN <br /> IM <br /> ' ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES I INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION . PRO TY E <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> a <br /> DISTANCETO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> i' <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> C7 SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> Cl DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> II <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIF AT I HAVE PREPARED THJ&-APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,S A AWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. i <br /> SIGNED: TITLE:6213-5U `` DATE: <br /> zb/Zr,*-v <br /> IE <br /> II <br /> u <br /> d <br /> I� O <br /> Ih WLSW V=L V <br /> a <br /> ay.r,A �n cu rlr <br /> itwru <br /> li =NV RO �hR „Ff <br /> h /yi1 n r!S?jfr <br /> it l <br /> II V <br /> yI <br /> it <br /> IM <br /> IM <br /> IM <br /> WART E T SEONLY . <br /> APPLICATION ACCEPTED BY: �— - � ATE: <br /> TANK, <br /> r <br /> TANK,PIT;OR SUMP INSPECTED Y: DATE: <br /> 'k <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> I� <br /> PE CODE SC AMOUNTHECK RECEIVED BY DATE PERMITlS£RVICE REQUEST# SEPTIC.ID# <br /> iI INFO REMITTED CASH <br /> w <br /> 1' <br /> u <br />