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y LIQUID WASTE PERMIT'.• <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> E 304 E.WEBER AVF.,3""FLOOR,STOCKTOON,CA 95202 (209)468-3420 R <br /> NON-REEUNDAIILE PERMIT EXPIRES I YI?AR FROM DATE ISSUED <br /> JOB ADDRESS—rI^i I N s F-11 - � <br /> CITYIZIP /C2�-I I �) i 1 PARCELSIZE/APN 1.7 <br /> OWNER NAME• ADDRESS -�SyI - ���-- 1 l <br /> !' / <br /> CITYIZIP t Jam- // PHONE <br /> CONTRT RAl_ er-L. uL�1°_ e ADDRESSU <br /> Cl ��l; i C r PHONE T3 �S L <br /> GEOGRAPHICAL INFORMATION: COORDIANTES' X Y TOWNSHIP�RANGESFCTION <br /> 1 <br /> PERC TEST(S) ( ) HOW MANY APPLICATION N: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [IDES]-IiU TION <br /> I INSTALLATION WILL SERVE: L7 RESIDENCE ❑COMMERICIAL xOTHER Al, A. <br />"i NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:— <br /> CHARACTER <br /> MPLOYEES:CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL,C14ARACTER: WATER T'ABLF DE1714 <br /> ❑SEPTIC TANK/GREASE TRAP TYPFJMFG COVIC IA?J CAPACITY Zp Q NUMBER OF COMPARTMENTS 2- <br /> .13 <br /> .O PKG TREATMENT PLANT DISTANCF TO NEAREST:' „WELL (Jg FOUNDAT'ION PROPERTY LINEJ-00 <br /> ❑LIFT STATION SIZE. TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> -P'L- ACHING LINE NUMBER&LENGTH OF LINES �I� INFILTRATOR CHAMBERS <br /> `' 2d <br /> 3 DISTANCE TO NEAREST: WELL /09 FOUNDATION- <br /> 11 FILTER BED WIDTH LENGTH DFPTI-( <br />' DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE' <br /> i <br /> ❑MOUNDED WIDTH LENGTH DEPTH ] <br /> DISTANCE TO NEAREST: WELL FOUNDATION I'ROPL'RTY LINE_ <br /> CI SEEPAGE PITS WIDTH LENGTH 'DEI'T'II II — <br /> DISTANCE TO N REST:. wrLj..�FOUNDATION PROPERTY LINE V 4 <br /> UNI.PS cam' WIDTH �_ LFNGTH DEPTH11-1 _�_ <br /> DISTANCE TO NEAREST: WELL IS U FOUNDATION l r - /-5e� PROPERTYLINE <br />- ❑DISPOSAL PONDS WIDTH LENGTH DEPTH - t <br /> j DISTANCE TO NFA REST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN,IOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ISI i <br /> SIGNED: TITLE:_ DATE: <br /> i <br /> L If Y <br />� a <br /> r CWHI roN qF1v ! _ iS_ . <br /> t <br /> tc <br /> Ij <br /> a <br /> l <br /> f <br /> h <br /> kV 1 IC4 (ryr777171 <br /> - — <br /> _ = _ <br /> 1 T, 7 1 1 r I <br /> FOR DEPA MENT USE ONLY - + - <br /> 1 <br /> "- APPLICATION ACCEPTED BY: - BATE: <br /> F <br /> TANK,PIT,OR SUMP INS <br /> PE J7 B DATE: <br /> FINAL INSPECTION BY�:IME S: <br /> �(�7� <br /> Ad <br /> �j 47 <br /> PI-CODE SI- AMOUNT •CK RECEIVED BY DATE PERMIT"/SERVICE REQUEST# _--d SEM'1C DW <br /> [NFO xl;Mn-rro CASH <br /> " �� Roogojo Co <br />