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LIQUID WASTE PERMIT ". r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3R°FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> L NON--REFUNDABLE PERMIT EXPIRES 1 YF,AR FROM DATC i55UED - �" ` `; •-k-.. <br /> JOB ADDRESS or�4 •S /^'YG� L 4441 3 -�Y �- }i -` E'-•. <br /> CITYM { K ZZ PARCEL«SIZE/APN <br /> OWNER NAME ADDRESS V0 ] Pr" -'d <br /> CITYIZ[p I� e r�TS (l S�ZZ PHONE �O `STr7C� 8 <br /> CONTRACTOR il-p- ADDRESS fr! <br /> CITYIZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOW,NSHIPRANGE —SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: M'NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: fir/ ?mss, t�Lta� <br /> —L_ NUMBER OF B DROOMS: � NUMBER OF EMPLOYEES <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: S6741 ��! PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH A/ w <br /> IR'SEPI'IC TANK/GREASE TRAP TYPE/MFG. C�'N l a h� 1�7pPACITY Z G 0 C> NUMBER OF COMPARTMENTS Q <br /> i ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL_��Zd FOUNDATION PROPERTY LINE SI - <br /> Cl LIFT STATION ZE W TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1!!'LEACHING LINE NUMBER&LENGTH OF LINES 3 / c�C_U INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST:. WELL -100 f FOUNDATION 4�-4- PROPERTY LINE�. <br /> ❑FILTER BED WIDTH LENGTH DEPTH [[ //�� <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY L'i�NE�YNI <br /> ❑MOUNDED WIDTH LENGTH DEPTH RE E I vE' r <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERT I�NEl r n <br /> Q SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERT' � ACNffi�CCUNT', <br /> 7CnLll I J�h. vF."I <br /> ❑SUMPS WIDTH LENGTH DEPTH NViRONMF.NTAI FiFAJPJ I-)IUl,%F,, <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 AVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ! <br /> ORDIANC TE L D RU AND REGULATIONS OF SAN JOAQUIN COUNTY, <br /> SIGNED. TITLE:�7e2-" C/2 DATE: S !� <br /> n Cz <br /> n I <br /> t <br /> N 0 <br /> 13 <br /> 14 <br /> ch <br /> Ll <br /> M <br /> 3' <br /> I <br /> FOR DEPARTMEUSE ONLY _ <br /> APPLICATION ACCEPTED BY: DATE:�� <br /> TANK,PIT.OR SUMP INSPECTED BY; DATE: <br /> FINAL INSPECTION BY: <br /> 1 <br /> CO MENTS: V� ✓ - r' `^- 1� (yt f 1, <br /> It <br /> PE CODE SC AMOUNT CHECK#/ RECEIVED BY DATE PERMITISERVICE REQUEST# SEPTIC ID# <br /> INFO Rr.MITTF. CASH <br /> r u <br />