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'n - <br /> LIQUID WASTE PERMIT f� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)466-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESSSNVQ 99VJ'0 9b e r, J-AHAN'I .14)'30 '7 r r ✓A/�/�4�j0 - - <br /> CITY/ZIP AC/a/"►PO PARCELLSIIIZE/APN 1F7,Z A` L <br /> OWNERNAMEt3�L1kPM.-'V0 ADDRESS I0JQi 7 ,�• -JA/4/4/✓I- <br /> CITYIZIP A C A-nij--V ^ ` PHONE <br /> A4 <br /> CONTRACTOR VA >; �Zj ADDRESS // X 3 <br /> Y53 > <br /> CITY/ZIP �u�y�G Kr eA /J Sig PHONE �P 47 /4U3 <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGESECTION <br /> PERC TEST(S) ( ) HOW MANY c;?_ APPLICATION#: 16/a Ml <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> 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 TANK/GREASE 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(ENCLOSEDCG <br /> 13LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHDISTANCE TO NEAREST: WELL FOUNDATION LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> O NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIF AT I HA#�L <br /> S APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STA AWS,ANLATIONS OF SAN JOAQUINCOUNTY. <br /> SIGNED: '1 TITLE: dl,l � DATE: <br /> C) <br /> FA 9L 1 P,4, Z � <br /> v E <br /> �-- <br /> r' <br /> t_T S UN Y <br /> H II 14 U VIS ON <br /> F'OR D ARTM'V USE ONLY <br /> APPLICATION ACCEPTED BY: a, <br /> 11 1 <br /> TANK,PIT,OR SUMP INSPECTED BY: __ DATE: /^'' Z r� <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PE CODE SC AMOUNT CRECIK.W RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO REMITTED <br /> �� j (5 V 3a 0 (r;0 <br />