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��I l LIQUID WASTE PERV- <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENI/C HEALTH DIVISION <br /> 304 E.WEBER AVE 3N'FLOOR,STOCKTON,CA 95202(209)"N-3420 <br /> 4\A/I 99NON.REFUND�ABYCLEMPERMIT EXPIRES CnRP�FROM ISSUED <br /> JOB ADDRESS I►Q�V I V 1 1 VV �I �ffTT�� t- APry O 1 Ifo- G PARCEL SIZE: <br /> CITV/ZIP Lo I BUILDINGPERMIT# <br /> OWNERNAME_��JY !MeS W9 C 'I ADDRESS <br /> CITj <br /> Y/ZIP P' O 5 ox 101 <br /> y�Clements C CA ly ? / PHONE NUMBER 20 9) 4-76 G4-06 <br /> CONTRACTOR ✓. A. PVIYI iJ k ADDRESS <br /> CITY/ZIP PHONE NUMBER <br /> GEOGRAPHICAL INFORMATION: COORDINATES: X Y TOWNSHIP RANGE SECTION <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> ❑ NEW INSTALLATION ❑ RESIDENCE NUMBER OF BEDROOMS: <br /> ❑ REPAIR/ADDITION X COMMERCIAL <br /> LI NUMBER OF EMPLOYEES: <br /> X DESTRUCTION <br /> ❑ ENGINEERED/ALTERNATIVE 6- <br /> CHARACTER OF SOIL TO DEPTH OF 3': PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> G <br /> ❑ PERU TEST(sI HOW MANY ,L, APPLICATION# <br /> ❑ SEPTIC TANK TYPE/MFG r-!3,(r¢-I'e, CAPACITY 10010 #OFCOMPARTMENITS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY #OFCOMPARTMENTS < <br /> ❑ PKGTXPLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE V <br /> ❑ LIFT STATION SIZE TYPE OF PUMPSAND OIL SEPARATOR(ENCLOSED SYSTEM) C( <br /> UU � <br /> ❑ LEACH LINE #OF LINES; J LENGTH OF LINES: 1_'T Q I DISTANCE TO NEAREST: WELL> 570 FOUNDATION PROPERTY LINE <br /> IN FLITRATOR CHAMBERS: —ham <br /> ❑ FILTER BED WIDTH LENGTH DEPTH_ DISTANCETO:NEAREST: WELL FOUNDATION PROPERTY LINE C <br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCETONEARESF: WELL FOUNDATION PROPERTY LINE C <br /> ❑ SUMPS WIDTH LENGTH DEPTH DISTANCETONEARESN WELL FOUNDATION PROPERTY LINE <br /> ❑ DISPOSAL FONDS WIDTH LENGTH ' p DEPTH DISTANCETORFARLST: WELL ,SA0FOUNDATION PROPERTY LINE r <br /> L3SEEPAGESEEPAGE PITS # 3 DIAMETER TII U <br /> DEPTH DISNCETONEAREST: WELL7I01 FOUNDATION PROPERTY LINE S 1 <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS <br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> /J/MAIM I{�M124-HO'U'R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PSL/EASE CALL(209)466-3423 <br /> SIGNED: �WU'�yyC7A.:/ � TITLE: V G"✓CSIB� DATE: <br /> LF <br /> SANJOAQUIN COUNTY. <br /> ` ENVIRONMENTAL HEALTHLpF,PAfl7Ey� _ <br /> _..I /\ <br /> SPECIAL PERWT <br /> r k y i ..tlesi�a�j T Py>y <br /> 0 <br /> { <br /> RR+RE i� oz MZEfm r <br /> ZiBIf6iQi CvxE i0N <br /> ... d <br /> --' i <br /> rCIfCE <br /> rl <br /> ....., r ��\G}�,�tNEA\-N� <br /> Y�'"� 191LPI <br /> _. <br /> (��, <br /> DEPARTMENT USE ONLY ,1 <br /> APPLICATIONACCEPTEDBY: az- DATE 11 ' T/ZAREA �I I EMPLOYEE IDM �q49-bISTRI('I T LOCATION <br /> INSPECTEDRO Y. f 11 eP J DATE: �L �Gj PERMITFINALJ`%YES DATEV_�/1+�."� I <br /> N <br /> SP <br /> E <br /> CTOR. <br /> COMMENTS: m all LV MPIiLr4Ia_T1 •I=i TIS rQ 1� ; l'.w..0� /�^E+lf, 1•44'',- -a�/EY]�fZ(lf��/M✓/ {�� <br /> DECODE SC INFO AMOUNTCHECKX4 SH RECEIVED DATE PERMITSER VICE REpUESTp INVOICEN SEPTIC IDM <br /> REMITTED BY <br /> 11 7-55 5401jai I <br /> 4221 015 99 S�{003 � 5'ET� <br /> REVMED4.I"' <br />