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LIQUID WASTE PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />304 E. WEBER AVE., 3"D I1.00R, STOCKTON, CA 95202 (209) 468-3420 ,- <br />Ob-RE <br />--rLlDLE PRIM EXPMES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS] ,( .� VKJ. <br />CITY/ZIP :r- / `�f <br />1a 3~ <br />e]}ci��] PARCEL SUWAPN—_.. <br />gtVl'IERNAM�- gl ADDRESS_ S <br />C1TYlZT-C :1:. %-'IQ -7 <br />N V"-i PHONE CTG S21 2 911 _— --- <br />CONTRACTOR--S j. '-+ ADDRESS M ----- <br />CIITYIZIP__ \A It-lo PHONE S A `i-NIZ <br />GEOGRAPHICAL INFORMATION: COORDIANTE3: X Y TOWNSHIP_RANOE_SECTION__ <br />PERC TESTS) ( ) HOW MANY _ APPLICATION N: _ <br />TYPEOFSEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU G <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERICIALR _([ • ��� <br />NUMBER OF LIVING UNPTS:_ NUMBER UP BEDROOMS:� NUMBER OFEMPI/LOYYEES :.., <br />C'H�IRACTSR OF S011. TO A DEPlI�i OF 3 FIiE"I: PIT/SUMP SOIL CHARACTER.-- WATER TABLE DEPTH <br />/U].1/_S,EPTIC TANK/GRRASE TRAP TYPEIMIr CAPACITY 1L-F_t/ NUMBEROFCOMPARTMENTS—Z <br />❑ PKG TREATMENT PLANT DINTANCETO NEAREST: WELI. FOUNDATION PROPERTYLINE <br />❑UPPSTATION SIZE TYPEOFPUMP SAND�rLSEPARATOR (ENCLOSED SYS'1'EM). <br />'U'I-HACHING LINE NUMBER & LENOTH OFIN <br />LES -4--J LA(�L f/INFILTRATOR C14A,*7MBERS j'y�' <br />DIS1'ANCETONEAREST: WfiLLFOUNDATIONv _ PROPERTY LINE>/ <br />❑ FILTER BED WIDTH LENGTH DEPTH <br />DISTANCETO NEAREST: WELL FOUNDATION;_ PROPERTYLINE <br />❑ MOUNDED WIDTH LENGTH, DEPTH <br />2` 9 DISTANCE 'TO NfARM: WELL FOUNDATION PROPERTY LINE <br />`-lL <br />EEPAGEPITS WIDTH `�w }F�� DEpTH 1 <br />DISTANCE TO NEAREST; WELL 2W FOUNDATION PROPERTY LINE f!den ( a- <br />❑ SUMPS WIDTH LENGTH DEPTH <br />DISTANCETO NRAREST: WELL FOUNDATION PROPERTY LINE ---------- <br />❑ DISPOSAL PONDS WIDTH LENGTH DEPTH <br />DISTANCE TO NEAREST: WELL _ FOUNDATION PROPERTY LINE <br />1 HERE TIFY THAT 1 HA VE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />URDIANB ATE A �j',A-NU R REG ATIONS OF SAN JOAQUIN COUNTY, <br />SIGNED:—'���}r`�=}�DAT7 <br />i <br />1 <br />--n-4I <br />I <br />I <br />_ 17' <br />R .1-F <br />Pklgo, HLiITH :[R !CL" <br />- — — Wr(14 A <br />♦ ONLY <br />APPLICATION ACCMFD BY:. _. Vv V' 4"� DATE I =7 <br />TANK, PT, OR SUMP INSPECTED Y: DATE. <br />FINAL INSPECTION BY: <br />COMM1IFJO'5: _ /7_ ,�i I {D7I �(fIO�ID./J �/I,trJ-,u—ww-f�LL Yh Od �O 076�X+"t - <br />PEt,'ODE SC AMOUNTCHECKM RECFAVED BY T <br />INFO REMMIll <br />DATE MIT/SrRVICEREquEsT#� SEPTIC" <br />`' ( -cam'" 1t3 -Pf-elMN-N7-C( 1 &- FS k'\i1 rl A Adl 441- (-P ct (nP -3 x47. :�, <br />nMAun <br />WF:I.I. PUMP PlRMR <br />�I <br />