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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH <br /> 304 E.WEBER AVE..3RD FLOOR,STOCKTON,CA 95202 (209)455-3420 R `,A..^� —ED <br /> Q NON-RF,FUNDABLE PERMIT EXPIRES 1 YEAR_F OM DATE ISSUED --• <br /> JOB ADDRESS �Q/��t� ' <br /> CITY>'ZIP / X4-c4/� �ff��� �� PARCEL SIZFJAPN <br /> /�A VR�- (d�"�+ ADDRESS 4�`� � <br /> OWNER NAME�,(� �} / <br /> *)o <br /> CITYIZIP GY 7Sj�fip PHONE <br /> CONTRACTOR ADDRESS ,,,�c�I9`Kp���`r <br /> PHONE 020 / LJ J?1 2 f. lO <br /> CITYfZIP nn <br /> GEOGRAPHICAL INFORMATION: COORD[ANTES: X Y TOWNSHIP`S RANGE SECTION <br /> 1 <br /> PERCTEST(S) HOW MANY 7/ APPLICATION#: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Xi REPAIRIADDITION ❑ DESTRU�J fIO��+N rr <br /> INSTALLATION WILL SERVE; ❑RESIDENCE COMMERICIAL ❑OTHER / ��Je h� L_ <br /> NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:k <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH r <br /> ❑SEPTIC TANKIGREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> *PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL>/V4 r FOUNDATIONSL PROPERTY LINE, d <br /> XfLIFT STATION SIZE f r TYPE OF PUMP .Sy>L4p SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES 1 INFILTRATOR CHAMBERS �4 <br /> f '+ DISTANCE TO NEAREST: WELL—FOUNDATION PROPERTY LINE <br /> �6LTER BED WIDTH J' 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 /> L <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 /> ORDIANCES,ST TE, S, N ULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: ! �G�+ R <br /> TLE: �h3Y`�EC.7d'IO Zll U A <br /> TI ^ DATE: <br /> II' , <br /> I � <br /> r - <br /> 7 <br /> c <br /> r <br /> / <br /> C: <br /> Es <br /> 4 Nis <br /> C <br /> G. . <br />