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LIQUID WASTE PERMIT <br /> G SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IIEALTH4440rHE <br /> P�r 304E WEBER AVE.,30.D FLOOR,STOCKTON,CA 95202 (209)468 3426SEfq <br /> R EC,.?U I=--S F <br /> NON-REFUNDABLE PERMIT FXPIRES I YEAR FROM DATF,ISSUE!? FC <br /> V � 7f7 �r � h���.2— 1NS�'���Tic7NS <br /> JOB ADDRESS <br /> CI'['Y/7.I1' PARCEL SIZEAPN_.�� + <br /> OWNER NAMES) ADDRESS JL4 141AE <br /> CITY/LIP ��j L PHONE <br /> CONTRACTOR 'I�`I"^ �(� !n�#��.__ ADDRF_SS <br /> C1TYR.IP PHON£ <br /> GEOGRAPHICAL INFORMATION: COORDIANTE.S: X-__ Y TOWNSHIP RANGESECTION <br /> PF..RC TEST(S) ( ) HOW MANY APPLICATION H: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION D DESTRU ON <br /> INSTALLATION WILL.SERVE: C]RESIDENCE NIMERICIAL THER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF <br /> CHARACTER OF SOIL TO A DEP'lIi OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SFP`TIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPER'T'Y LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> E CH1NG LINE NUMBER&LENGTH OF LINES _I f INFILTRATOR CHAMBERS-' <br /> -.____ <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> ❑FILTER BED WIDTH - LENGTH_ DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCI{TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 17 SEEPAGE PITS WIDTH LENGTH DEPTH *_- <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY L1NEII <br /> ❑SUMPS WIDTH LENGTH _ DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,AND RUL ''AND ULATIONSS F SAN JOAQUIN COUNTY. <br /> S[GNED: �f <br /> TITLE:�+In <br /> 6 <br /> _I <br /> 4 0 — <br /> A <br /> C <br /> r11U. X (!r <br /> a - I <br /> C <br /> PUELI <br /> FOR EPARTNI NTUSEONLY - <br /> APPLICATION ACCEPI'ED BY: [ l �' _ DAT O� L <br /> TANK.PIT.OR SUMP INSPECTED Y: __ DATE: uott <br /> FINAL INSPECT N BY: <br /> COMME S: C <br /> PECODE SC AMOUNT t! p1 RECEIVED DATE PERNIMSERVICEREQUESTA SEPTICID✓F <br /> INK) REMB'IED Exsfi <br /> �4b -115-- j - 0 z - <br />