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' LIQUID WASTE PERMIT �l �_� �T C <br /> SAN JOAQUIN COUNTY PUBLIC HEAL'T'H SERVICES ENVIRONMEN'T'AL IIEALT I DIVISION <br /> 304 E.WEBER AVE.,3""FLOOR,STOCKTON•CA 95202 (209)468-3420 Fi E�C� )E=7 r�;-F F <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED -�a /A L_ <br /> ]OB ADDRESS 3'yy ,G, /igJ - <br /> CITYIZIP <br /> PARCEL SIZEIAPN11(;2Ae. <br /> OWNER NAME)�i G'S �!ErV ADDRESS'-"PO I?Cf) <br /> CITYIZIP Cr E� M44e1f �+ PHONE C3 rP.3 �j(n C1 <br /> CONTRACTOR Se l7'�7 62 w ADDRESS <br /> i <br /> CITYIZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGESEC <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: CIYNEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: Ifa'RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:-3p NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: a 1[m/ PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> 0 SEPTIC TANIVGREASE TRAP TYPE/MFG a✓�f C ACITY /C,Ca c? NUMBER OF COMPARTMENTS,�f11PKG TREATMENT PLANT DISTANCE TO NEAREST: W!LL r QPOUNDATION PROPERTY LINE <br /> - <br /> 0 <br /> ��❑LFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 11QC.EACHING LINE NUMBER&LENGTH OF LINES /y0 r INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL -4- FOUNDATION a-r PROPERTY LINE ' <br /> ❑FILTER BED WIDTH LENGTH DEPTH pp�..,�� <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPER'IIYi!LVE 3 P N'l' <br /> El MOUNDED WIDTH LENGTHDEPTH RECiEI�,�I_i._i <br /> 'DISTANCE TO NEAREST: WELL FOUNDATION PROPSYILINF <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH J, - <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPEA3NlJlsllYJ#Ll!IJ i;OUNTY <br /> PU6LIC I .' �' }(>'FS',_ . <br /> ❑SUMPS WIDTH LENGTH DEPTH FNVIRONfvlfl�E� � I(II <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 C Y THA_T41rAVEPR PARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE W11 D Ut9t6UNTY <br /> ORDiANC TE S R ES AND REGULATIONS OF SAN JOAQUIN COUNTY. � I Li1LI i ALTH CS <br /> FNVIRONMENTAI H�gLTHICEs+�' <br /> SIGN TITLE: <br /> DATE: <br /> 7- <br /> A/F <br /> a- <br /> i <br /> f1 + <br /> Z >� IA <br /> qr <br /> �2 tr <br /> o <br /> -A <br /> 4 <zLLI <br /> FOR DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY: �Q 1 / DATE: �_� 7 <br /> i <br /> TANK.PIT,OR SUMP INSPECTED BY: DATE: <br /> FINAL INSPECTION BY: ' <br /> COMMENTS: <br /> DECODE SC AMOUNT CHECK#1 RECEIV BY DATE PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO RrM[7TEU CASH <br /> 03 <br /> b <br />