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� �rr LIQUID WASTE�PERMI- <br /> S7DAQUIN COUNTY PUBLIC HEALTH SERV ICES ENVIRONMENI*,,#IALTH DIVISION <br /> 304 E.WEBER AVE 3N'FLOOR.STOCKTON.CA 95202(209)46N-3420 <br /> JOB ADDRESS 3RD �e� NOEF'(pIDABLi;PERMIT E%APNi:S �`'(`^ATF:TUED PARCEL SIZE: <br /> CITY/ZIP ���/ ((fix//// BUILDING PERMITT# rr CC VV VV T' <br /> OWNERNAME-p— %{! ' V`'I ADDRESS /J4 <br /> CITYIZIP PHONE NUMBER `� <br /> CONTRACTOR - /C/ `-a/oP,�'/ V 1'� ADDRESS /- I 1 (o IJ�A</C.LX1C/^r rI <br /> CITV/ZIP PHONE NUMBER ' <br /> GEOGRAPHICAL INFORMATION: COORDINATES: % Y TOWNSHIP RANGE SECTION <br /> i <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> ❑ NEW INSTALLATION O RESIDENCE NUMBER OF BEDROOMS: <br /> �REPAIR/ADDITION �AMMERCIAL <br /> (❑ DESTRUCTION /❑ OTHER NUMBER OF EMPLOYEES: .S <br /> ❑ ENGINEERED/ALTERNATIVE <br /> CHARACTER OF SOIL TO DEPTH OF 3'• .,fkY PIT/SUMP SOIL CHARACTER WATER TABLE DEPTH:�'r` <br /> ❑ PERC TEST(S) HOW MANY APPLICATION# <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY #OFCOMPARTMENTS _ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY #OFCOMPARTMENTS <br /> ❑ PKGT%PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ LIFTSTATION SIZE TYPEOFPUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> r <br /> LEACH LINE NOFFL LINES:R LENGTH OF LINES: 4/0 <br /> IN <br /> DIATANCEMNEARERT: WELL FOUNDATION t/PROPERTY LINJ <br /> NFLITRATOR CHAMBERS: <br /> ❑ FILTER BED WIDTH LENGTH DEPTH DISrAROETONEARIR '. WELL FOUNDATION PROPERTY LINE <br /> ❑ MOUNDED WIDTH LENGTH DEPTH_ DPWANCETONEARM: WELL FOUNDATION PROPERTY LINE <br /> ❑ SUMPS WIDTH LENGTH DEPTH_ Dlz ANCETONEA IUW! WELL FOUNDATION PROPERTY LINE <br /> r❑ DISPOSAL PONDS WIDTH LENGTH �J DEPTH ']_ DI"ANCETONEARLW: WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE PITS # DIAMETERJ ' DEPTHJ`'�, DHWAN<ETONEARcsn WELT L^C FOUNDATION 60,10— <br /> (1 PROPERTY LINE/L <br /> is o <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 /> MI 424 RA NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)46R-342,7 f <br /> SIGNED: TITLE: -DATE: <br /> 3 _Z ` L <br /> _ <br /> i - <br /> L2 <br /> _-. L <br /> I I <br /> I I _ <br /> r i <br /> C <br /> Di:PA M •NT USE ONLY B <br /> APPLICATION ALBP'TED BY: T 7GY AREA �� EMPLOYEE^IDr ���DIbTRICTLZ LOCATON <br /> I <br /> INSPECTED BY:_-]� DATE: �D7- PERMIT FINAL OPYES DATE:�t�IN�OR: /J <br /> COMMENTS: <br /> PECODE SC INFO AMOUNT CHECK [ASH RECDATE PERMD5ERVICE REQUESTII INVOICBT SEPTK HM <br /> REMITTED BYEIVED <br /> Ll 2-1 <br /> REY tl)LIHI ^ ^ <br />