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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER\'ICES ENVIRONMENTAL HEALTH DI WL91Q �v C�e i {_ <br /> 6 304 E.WEBER AVE.,3"D FLOOR,STOCKTON,CA 95202 (209)466-3:20 RT <br /> per} <br /> NONREFUNDABLE PERMIT EXPIRFS I YEAR FROM DATE ISSUEDv <br /> JOB ADDRESS -A/011 <br /> CITYrzIP /f) j i�/a TF1,BYO PARCEL SIZE/APN <br /> ' OWNER NAME Al« /1A/,f I I)04 z j:MP ADDRESS � ` -ro 1L4 y 'L'/oa <br /> yy CITYrtle 1A/)T <br /> CONTRACTOR LIP I-I. n. A A_�114E 4,oj 1 ADDRESS 2 11'1'15'Tf)AI /Il U E <br /> CITYM? /,-00 T- /'.Q q_�,'Y4 PHONE (-Qq_) '11n�Z- 701 <br /> k GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP.�4LRANGEI�LSECTION <br /> PERC TEST(S)(/HOW MANY APPLICATION N: N`5-T7-2D <br /> 1- TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE' ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> i• NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> '^ CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANKIGREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ..� ❑FILTER BED WIDTH LENGTH DEPTH _ <br /> DISTANCE TO NEAREST:WELL FOUNDATION: PYH7IVIC <br /> ❑MOUNDED WIDTH LENGTH DEPTH RECEIVED <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LI <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH FEB O 1 2091 <br /> a DISTANCE TO NEAREST: WELL FOUNDATIONPROPERTY Llt� <br /> _ SAN JOAOUIN GC3DNT� <br /> ❑SUMPS WIDTH LENGTH DEPTH PUBLIC HEALT H SERVICES <br /> ZNVIRONMENTAI HEALTH DIVISION <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH i <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ' <br /> i I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORD WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDLANC TP WS,A$D RULES AND REGULATIONS OF SAN.JOAQUIN.COUNTY. <br /> SIGNED: I �. I ll TITLE:Xry( DATE:2-7-c)) ,. <br /> r -I I r •� I i. f � � I I <br /> i <br /> 0- <br /> N I SNIiN- f, _ <br /> 1 Lc�k'noN cP r2�G-col-a-noa I I�IY� � <br /> f`�i- � ,� i N##N'w• a"uu•n'« T mcr u ?-,� <br /> Y#� C <br /> c <br /> v <br /> J 1 `PROPOSED'IARC£L I PROPOSE__WC£L 2 s 1 r <br /> cu SITE <br /> s -5.00 ACRES GROSS 4,09 ACRES 61;055 <br /> - - 4.55 ACRE! NET y`Y 4.84 ACRES NR. <br /> rO ` <br /> z <br /> ' 1 VICUTY MAI <br /> .., •$ :" ,-� � E � `n n 00 #0 1d'. k eql)0 SG1f r ..+'. <br /> '.Q"017'• Ilp� 1 MCN J00 R I �-r <br /> rl#[W <br /> I <br /> FOR FEPAR' USE ONLY <br /> (/` } <br /> APPlJCA770N ACCEPYED BY `' " ✓""-� `�-• D.ATE'_'�A <br /> TANK.PR.OR SUMP INSPECTED BY: DATT:. <br /> FINAL INSPECTION BY. <br /> ®r <br /> COMMENTS: <br /> PECODE SC AMOUNT CHECK#/ RECEIVED BY DAIS PERMIT/SERVICE REQUFSTO SEPTIC 8711 <br /> INFO REMITTED CASH <br />