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LIQUID WASTE PERMY <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP l V�� 1 1 PARCELSIZE/APN 06 l— <br /> OWNER NAME I•r��,rT 1- P V l V SIS! VIDI)RESS Q0 RI) U77 1 <br /> CITY/ZIP �00 __ PHONES <br /> CONTRACTOR��QQ1� �p �� ADDRESS�/� / US�`� <br /> CITY/ZIP_ od 0,\N PHONE (/ j i3K67 /0 It <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP—RANGE—SECTION <br /> PERC TEST(S)�HOW MANY[ APPLICATION k: 66 -01-77 <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(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY 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 /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANC ,STATE WS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. }— <br /> SIGNED: TITLE:/� 1l[ 1 DATE: <br /> c <br /> C <br /> FOR DEPARTMENT USE ONLY /� �/�p <br /> APPLICATION ACCEPTED BY: �� f-/L ✓ DATE: (`� I� <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE: _ <br /> y <br /> FINAL INSPECTION _ .�'« --// �!-1���r � i�i <br /> COMMgNTS: _ rte:1." KI `r7- " f: <br /> ? /1 I./�� <br /> PE CODE. SC AMOUNT CK 40 RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO ROMPITED ASH <br /> 1004 qFW <br /> 1 � � <br /> l S' '�' / l. fig ![. /-<7- .✓� r�/_ <br />