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Hill <br /> LIQUID WASTE PERMIT Zo - <br /> SAN JOAQUI:. .OU NTY PUBLIC HEALTH SERV ICES ENVIRONMENTAL Ham. .fH DIVISION /N!-�"t <br /> 304 E.WEBER AVE.,3"D FLOOR,STOCKTON,CA 95202 (209)468-3420 7 <br /> NON-RFFU DABLE PERMIT F„'PIRES I YEA 1 5, <br /> JOB ADDRE <br /> I3 /' ' � <br /> SS <br /> CITY/ZIP �b�%f PARCEL SIZFJ P — 7 <br /> OWNER NAME AV IV P >J�V i — SY-94(e-fV4 ADDRESS <br /> CITY/ZIP�/IA Dd �i ry 1�,�/3 PHONE <br /> CONTRACTOR�l' /%i/Ji��y��Y/�— ADDRESS <br /> CITY/ZIP 5 r'?J(,rL�r' S 5�7�0 PHONE °l 4 <br /> GEOGRAPHICAL INFORMATION: COORDIIA�NTES: X Y TOWNSHIP RANGE_SECTION C n 1 <br /> PERC TEST(S) (Xi HOW MANY `�7 APPLICATION#: DAY^Mr `G,'v� <br /> TYPE OF SEPTIC WORK: /❑\ NEW INSTALLATION ❑ REPAIR/ADDITION 13 DESTRUCTION REvG1v E� <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER 'toxo <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:— <br /> CHARACTER <br /> MPLOYEES:CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: W<�T $�"� <br /> pp UC HEAD <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPAR"1',(v����(gjENTAL HFAIJN�IVISI�Pd <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINEtt�I�V`"'11 _ <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 DEMI <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 CERTIF TH��IJEPAJ�ED THIS APPLICATION AND TME WORK�V'ILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,S ' D REGULATIONS OF SAN JOAQUIN COUNTY. r <br /> SIGNED: ` TITLE: SS I /" DATE: ( �j <br /> VIT <br /> Vv <br /> V , <br /> ` . <br /> S iS L • , <br /> FOR "TMENT USE ONLY <br /> APPLICATION ACCEPTED BY: JF�, /�ri -,•/,`/,` DATE: <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE:- - <br /> FINAL INSPECTION BY: 74 <br /> COMME S: <br /> PkCODE SC AMOUNT CH "EC RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC IDN <br /> INFO REMITTED SH <br /> Sal 3 yolz3 -Z�v �YZ� <br />