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LIQUID WASTE PERMIT SAN JOAQUIN COLIISTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALT 0814q 304 E.WEBER AVE.,3ID FLOOR,STOCKTON,CA 95202 (209)468-3420 c�u sC�.- s-- E C J NON-REFUNDABLE P,KNIT EXPIRES 1 Y DA OF JOB ADDRESS C1TYlZIP PARCEL SIZF)APN OWNER NAME ESS CITYIZIP PHONE ~ CONTRACTOR ADDRESS PHONE CITYIZIP ZEOGRAPHICAL INFORMATI •N: COORDIANTES XX Y TOWNS HIP�RANGE SECTION PERC TL"-ST(S) ( ) HOW MANY APPLICATION TYPE OF SEPTIC WORK: Cl NEW INSTALLATION ;[3 R R/ADDITION ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑RESIDENCE COMMERICIAL ❑OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:- CHARACTER MPLOYEES:CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH I I ❑SEPTIC TANKIGREASE TRAP TYPEIMFG CAPACITY 61g NUMBER OF COMPARTMENTS C]PKGTREATMENT PLANT DISTANCE TO NEAREST: WELL OBJ`"'FOUNDATION PROPERTY LINE- ❑LIFTSTATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) i ❑LEACHING LINE NUMBER&LENGTH OF LINES 1 -'f INFILTRATOR CHAMBERS r� - DISTANCE TO NEAREST: WELL �OUNDATION U PROPERTY LINE [' ❑FILTER BED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE h\ ❑MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ❑SEEPAGE PITS WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ❑SUMPS WIDTH LENGTH DEPTH "\ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ❑DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE 1 •� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY �} ORDIANCES. TATE LAWS,AND R ES AND REGULATI S OF SAN JOAQUIN COUNTY. ��D SIGNED: TITLE: DATE: � � - I I p r d 1:! i tl FOR DEPARTMENT USE ON Y - APPLICATION ACCEPTED BY: - 0011 1� DATE: TANK,PIT,OR SUMP INSPECTED BY: DATE: FINAL INSPECTION B COMMENTS: PECODE SC AMOUNT RECEIVED BY DATE PERMTT/SERVICE REQUEST# SEPTIC IDN INFO "REMITTED CASH Z 41450 e) ?.3