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` _, ' LIQUID WASTE PERMIT ` -. ,-- <br /> SAN <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3"FLOOR,STOCKTON.CA 45202 (209)46&3420 <br /> NON-RFFUND60LE PERMIT EXPIBF-% <br /> I{ ! <br /> JOB ADDRESS � � r <br /> ClTYfZIP�!�� Wti - 1�. _PARCL'L51W�APN <br /> a / <br /> OWNER NAM L" t _u ! ADDRESS t II r I f <br /> 1 CITY/LIP ai PHONE I .� t <br /> CONTRACTOR I\t` Crte- ---— _ ADDRESS <br /> CITYfzIP•_•_ C2d, ___PHONE <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP�ANOE:__SECITON <br /> i -0 <br /> PERC TESTIS)( IOW MANY _ APPLICATION N: <br /> TYPEOFSEPTICWORK: ❑ NEW INSTALLATION 13 REPAFPJADDMO14 ❑ DEsTRUCIION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> _ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:— NUMBEROFEMPLOYFES:— <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH,._,^ <br /> ❑SEPTIC TANKIGREASETRAP TYPEIMFG CAPACITY NUMBER OFCOMPARTMENIS <br /> d ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE J <br /> { ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 13 LEACHING LINE NUMBER&LENGTH OFLINES I INFILTRATOR CHAMBERS <br /> 1 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ,. <br /> Ir - O FILTER BED WIDTH LENGTH DEPIN <br /> DISTANCETO NEAREST: WELL FOUNDATION: PROPERTY LINE - r1 <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: 1l'f:l.l_ FOUNDATION PROPERTY LINE ' <br /> F <br /> 13 SEEPAGE PITS WIDTH LENGTH I*17H -- <br /> DISTANCETO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> Fj ❑SUMPS WIDTH LENGTH DEITH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LFNGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINL <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE STORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> F ORDIAN"S,.STATE LAWS.AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNS _ -_ITTL . J BATE: �� <br /> F1 �t <br /> (A".9 <br /> ti a <br /> f T� RN <br /> ;nix <br /> f � S'� Z17d311 <br /> A <br /> lit <br /> j JL AD 10 <br /> ! s � <br /> eI <br /> r <br /> Pok DEPARTMENT USE ONLY <br /> �F APPLICATION ACCEPTED BY: -'1 -'• DATE: <br /> 3D <br /> � TANK.PCT.OR SUMP MSPECTEU BV: ATE r, <br /> FINAL INSPECTION BY: <br /> COMMEI•I'M <br /> C-+ PE CODE Sc AMOUNT 'CHECK a/ RECEIVED BY DATE PERMITISERVICE REQUEST r SEP11C 1D1 <br /> INFO REMITTED __rAZw1 <br /> f <br />