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MA LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIC)N,y " ' ` <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 GG <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / ] f— <br /> CITY/Zip <br /> Ac-s <br /> CITY/ZIP [1C-J �'(�� �� PARCEL SIZ(E�/APNI 1 ! / t,...-s 10 3 -,2�o-01 <br /> OWNER NAME 1 1 C-_e4t j) ie r rG 4a <br /> C ADDRESS <br /> CITY/ZIP :5 I-o C 'L —lw g Lj `J PHONE 94141—941 S / <br /> CONTRACTOR ADDRESS <br /> CITY/ZIP PHONE ' <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP RANGE SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 11 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 /> f . <br /> E'PTIC TANK/GREASE TRAP TYPE/MFG 'CAPACITY1 h 1 0_ NUMBER OF COMPARTMENTS_ <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL 4 , FOUNDATION 0 '/PROPERTY LINE <br /> VLEACHING <br /> IFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LINE NUMBER&LENGTH OF LINES - / �/ INFILTRATOR CHAMBERS [ <br /> DISTANCE TO NEAREST: WELL 00 FOUNDATION S �ROPERTY LINE `d� <br /> ❑FILTER BED WIDTH / LENGTH DEPTH_ <br /> DISTANCE TO NEAREST: WELL�_ FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> 6(,(DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> PAGE PITS TH L DEPTHL <br /> DISTANCE TO NEAREST: WELL FOUNDATION .__It,�' 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 THISAPPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES ATE LAWS,AN ES AND REG ATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: x TITLE: ✓— DATE: ®} <br /> X <br /> O <br /> S <br /> O <br /> .3 <br /> \ �4- <br /> �S <br /> ZPJTj <br /> � h � <br /> G? <br /> acrJ74� it C <br /> AjG <br /> N SA <br /> \ ENVIRNB�C'uAGU T <br /> \ EN t .AL S <br /> ,i N <br /> J 7 <br /> FOR DEPARTMENT US L <br /> J <br /> ---- =-4PP61CA`t'i0�'ACCLPTED BY: - -.� •. -Z,� 1 r� .,�,.. <br /> OR SUMP INSPECTED Y: DATE: - -- <br /> FINAL INSPECTION BY: <br /> COMMENTS: - <br /> PE CODE SC AMOUNT CHECK RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO REMITTED_ <br /> 1100 oL <br />