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�- LIQUID WASTE PERMXT <br /> SANIOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 1?WEBER AVE„3RO FLOOR STOCKTON,CA 95202 <br /> (209)468-3420 y <br /> ON-REF NDAB F,]PERMIT EXPIRES] YEAR F M DATE fSSUED i <br /> 108 ADDRESS �� <br /> UG/G �✓ I <br /> CITY/ZIP <br /> PARCEL SIZEIAPN. <br /> I OWNER NAME — — <br /> ADDRESS S <br /> CITYIZIP e L�AA/ <br /> (^ PHONE "J11 <br /> CONTRACTOR <br /> 11 C1TYMP [ ADDRESS <br /> pp 5 <br /> 1/✓ �L._ R D PHONE <br /> 21 i <br /> "... <br /> r-, GEOGRAPHICAL INFORMATION: COORDIANTE& X � <br /> ". Y TOWNSHIP RANGE—SECTION <br /> PERC TEST(S) ( ) HOW MANY` <br /> TYPE OF SEPTIC WORK: APPLICATION#: S <br /> . NEW INSTALLATION ❑ REPAIR/ADDITION <br /> .—� INSTALLATION WILLSERVF: ❑RES ❑ DESTRUCTION <br /> 3 <br /> RESIDENCE ❑COMMERICIAL d <br /> i J I�UMBEROFLIVING UNITS: ❑OTHER <br /> NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: �r�M� <br /> fM PIT/SUMP SOIL CHARACTER <br /> �SEPTIC TANiVGRFASE TRAP : WATER TABLE DEPTH <br /> l <br /> �h TYPFJMF U <br /> E i ❑PKG TREATMENT PLANT —L CAPACITY NUMBER OF COMPARTMENTS I <br /> iY DISTANCE TO NEAREST: WELL <br /> ❑LIFT STATION SIZE FOUNDATION PROPERTYLINE_,�� <br /> TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Cl LEACHING LINE NUMBER&LENGTH OF LINES i~^" <br /> h _ INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELLRI:�'Q <br /> ❑FILTER BED FOUNDATIpN 2U <br /> WIDTH PROPERTY LINE�^ <br /> r" LENGTH ' <br /> DEPTH <br /> DISTANCE TO NEAREST. WELL <br /> F ❑f MOUNDEDWIDTH FOUNDATION;— PROPERTY LINE <br /> LENGTH <br /> —� DEPTH <br /> r--� DISTANCE TO NEAREST; WELLI ' <br /> G EPAGE PITS WIDTH FOUNDATION <br /> 13 SE — PROPERTY LINE_ <br /> --�� LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELLffl �~ <br /> FOUNDATION PROPERTY L1NF <br /> SUh[PS WIDTH LENGTH , DEPT'H 40 <br /> DISTANCE TO NEAREST: WELL -_ <br /> ❑DISPOSAL PONDS WIDTH FOUNDATION PROPERTY LINE <br /> 4 — � LENGTH DEPTH <br /> e" DISTANCE TO NEAREST; WELL 11I <br /> 1 HEREBY .FOUNDATION_ <br /> CERTIFY THAT I PROPERTY LINE <br /> HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN CCA ORDANCE WITH SAN JOAQUiN COUNTY Ili <br /> ORDIANCES, ATE LAWS <br /> .—ES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> l <br /> SIGNED: _ <br /> p <br /> TITLEc 1 y <br /> DAT <br /> `p j <br /> C <br /> 4I <br /> i <br /> 1 i <br /> f <br /> U F <br /> i y l <br /> I f 15 / I Ii <br /> f 5 <br />