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LIQUID WASTE PERK <br /> JOAQll3o E4 EO Wf SER AVE 3 FLOOR,STOCKTO NCA 045202{209)46K-3420 DSV I5l0 <br /> NON-REFUNDABLE PERMIT EXPIRES l YEAR FROM DATE ISSUED - <br /> .APN O i PARCEL SIZE' <br /> JOB ADDRESS <br /> •��.. <br /> S� S <br /> r � BU1LUlNC PERMIT# <br /> CITYIZIP 5,7 <br /> (}WNERNAh1E �O ADDRESS <br /> zoo 3 G 7 0T,3 0 <br /> C1TYlZIP X35. s�a� <br /> PHONE NUMBER /zlL�/1tO <br /> , <br /> ADDRESS 6- 72 <br /> CONTRACTOR, <br /> PHONE NUMBER <br /> C ITYIZI P_¢_= <br /> GEOGRAPHICAL INFORMATION: COORDINATES: X <br /> Y •TOWNSHIP. RANGE SECTION <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> i. <br /> ❑ NEW INSTALLATION ❑ RESIDENCE NUMBER OF BEDROOMS: <br /> ❑ REPAIR/ADDITION ❑ COMMERCIAL NUMBER OF EMPLOYEES: <br /> 5<DESTRUCTION ❑ OTHER <br /> ❑ ENGINEERED/ALTERNATIVE. <br /> CHARACTER OF SOIL TO DEPTH OF 3': PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> II <br /> ❑ PERC TEST(S) HOW MANY APPLICATION# <br /> ❑ 'SEPTIC TANK TYPEIMFG_ CAPACITY #OF COMPARTMENTS <br /> Q GREASE TRAP TYPE/MFG CAPACITY #OF COMPARTMENTS <br />�I ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE - <br /> ❑ LIFT STATION SIZE TYPEOF PUMP - 'i SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1 Cl LEACH LINE #OF LINES: LENGTH OF LINESt - DLSTANCETO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I <br /> INFLITRATOR CHAMBERS: <br /> ❑ FILTER BED WIDTH LENGTH DEPTH V DISTANCE TO NEAREST: WELT. FOUNDATION PROPERTY LINE <br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> i 1 <br /> ❑ SUMPS WIDTH LENGTH DEPTH • DISTANCETONEAREST: WELL FOUNDATION .PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH LENGTH -DEPTH. DISTANCETONEARK.W: WELI, FOUNDATION PROPERTYLINE ( <br /> S <br /> ❑ SEEPAGE PITS # DIAMETER DEPTH. LAST ANC ETONEAREST: WELL FOUNDATION PROPERTY LINE <br /> E I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANDTHE WORK WILL HE DONE IN ACCORDANCE WITII SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS <br /> i <br /> AND RULES AND REGULATIONS OF SAN JOA QUIN COUNTY, <br /> 7U#1'4 HOURA ' CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)468-3423 <br /> SIGNED: ✓ " TITLE: DATE: <br /> _ .. - <br /> : <br /> ..,.. - - <br /> 01 <br /> .. <br /> .. a. .....-_- ..,..,..,., .....i ..... .. .. . _- -. .. <br /> I' .. ..,.-.. .. -- <br /> � c � .. - <br /> Jr�i�� <br /> - <br /> W .... <br /> V_.. .. . : <br /> �cP SIF I <br /> I <br /> : - -- <br /> ............ <br /> I ,DEPARTMENT SE NLV <br /> APPLICATION ACCEPT Y' DATE:U loo,AREA EMPLOYEE ID DISTRICT CZ--LOCATION <br /> INSPECTE BY _ DATE:�/< O2 PERMIT FINAL Cl <br /> YES DATE: INSPECTOR'. - <br /> COMMENTS:' ` .��C�!�-1.� -4J l J [.c�c�t'6G- CIC.L'Y it G�•[.Gf -GS L.r—~I°���[-.C`J/ e.� <br /> PE CODE "SC INFO AMOUNT CHECKd! SN It ECEIVED DATE PERM ITSERVICE REQUESTN INVOICE# - SEPTIC IDk <br /> REMITFED BY - <br /> REVISED R-15.01 . <br />