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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE._,3R°FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> OB ADDRESS_' <br /> i r. <br /> C[TY2.IP_ �i,t J.'��2�.�L/ {���'�_ t�__-� PARCF.I_SIZElAPN <br /> OWNER NAME ?�� GAJ iJ/l ADDRE5 � � <br /> CITY/ZIP_ PHONE '*?, <br /> CONTRACTOR /�./���}y �s-SIC � r !L}'.s�, i' f �t% ADDRESS_ <br /> CIIYIZIP <br /> PHONE_ I -14 J <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: R Y TOWNSHIP RANGE SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEl'7'IC WORK: ❑ NEW INSTALLATION �EPMR/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: PITISUMP SOIL CHARACTER: WATER TABLE DEPI'H <br /> ❑SEPTIC TANKlGRFASE TRAP TYPE/MFG— CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PI,ANT 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: WIj_LI., L l)l FOUNDATION 7<__ -ROPERTY LINE r <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL FOUNDATION- PROPERTY LINE <br /> ❑MOUNDED WIDTH _ LENGTH_ DEPTH <br /> DISTANCE TONEAREST: WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE PICS WIDTH -1'6 LENGTH _ DEPTH '­ <br /> DISTANCE TO NEAREST: W£LLI__,�`.-f% C�FOUNDATION , PROPERTY LINE " <br /> 0 Sumps WIDTH LENG'T'H DEPTH <br /> DISTANCE TO NEAREST: WELL FGUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTI'I LENGTH DEPTH <br /> DISTANCE TO NEAREST- WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERM THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DOVE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES� T�LAWS.,AND SAN REGULATIONS dF SAN JOAQUiN COUNTY. <br /> SIGNED: ,_�' _ __.-TITLE: � DATE: - <br /> 1 <br /> 1116 <br /> w r <br /> I <br /> 4 <br /> I ! ! <br /> l I <br /> ! r <br /> Y� <br /> FOR DEPARTMENT USE ONLY � (� <br /> APPLICATION ACCEl>I'ED BY: <br /> DATE: <br /> TANK.PIT' <br /> OR SUh1P[NSP ED --DATE����f f <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PECODE SC AMOUNT r CHECK#1 T RECEIVEDBY DATE TTI UESTk SEPTIC IDN <br /> INFO RFMITTED <br /> y2 <br />