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LIQUID WASTE PERMIT `/ SEPTIC <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3RO FLOOR,STOCKTON,CA 95202 (209)469-342Q�'l <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS //y�.����..��-yy--�� /'J -7 �j� q - 'Lo � 'ItJIWI <br /> CITY/ZIP A'�Vv- 05V D PARCEL SIZF//AyPN�� I '�`� `� <br /> �/� ADDRESS ►SCDI oWIS -DSP r-- <br /> OWNER NAMEy�v`J�� ��� ��/� Q <br /> �f/q PHONE LlJ", •.4-f- ���o <br /> crTY21e 'IF/�" qCH5 O 'pnr4kM Anlr - <br /> CONTRACTOR 1 rte�..11,� 'rJ �jN FiQ 117 AtS7V9AcS wq PHONE ADDRESS ' n A� <br /> CITY/LIP YfbL.l�-'�ti •r ^/ 1, <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X—Y—TOSH�RANGEGSE(-TION <br /> WN <br /> PERC TEST(S) ()Y HOW MANY APPLICATION O: V6 �L— <br /> ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> TYPE OF SEPTIC WORK: 13 NEW INSTALLATION a�OTHER Ta�Knr1�� �AF�'P <br /> INSTALLATION WILL SERVE: ❑RESIDENCE [3 COMMERICIAL V NUMBER OF EMPLOYEES:_ <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS:_ <br /> PIT/SUMP SOIL CHARACTER:- WATER TABLE DEPTH <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: NUMBER OF COMPARTMENTS <br /> — <br /> 0 <br /> TANK/GREASE TRAP TYPFJMFG CAPACITY PROPERTY LINE <br /> ❑PKG TREATMENT P1-ANT <br /> DISTANCE TO NEAREST: WELL FOUNDATION <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> / INFILTRATOR CHAMBERS <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES oROPERTY LINE <br /> DISTANCE TO NEAREST: WELL FOUNDATION <br /> ❑FILTER BED WIDTH LENGTH DEPTH N <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL <br /> FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL <br /> FOUNDATION PROPERTY LINE- <br /> 0 <br /> INE❑SUMPS WIDTH LENGTH DEPTH ! !� <br /> DISTANCE TO NEAREST: WELL <br /> FOUNDATION PROPERTY LINE V > <br /> 13 DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL <br /> FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN iCOUNTY <br /> ORDIANCE$,STATELAWS,AND RUL ND REGULATIONS OF SAN JOAQUIN COUNTY- <br /> SIGNED: <br /> k DATE: <br /> SIGNED: <br /> 71J\fliMA JIB 9//��� TITLE:—IA <br /> n+ <br /> tar-- -- - _.. <br /> At <br /> it <br /> vre� <br /> _. A <br /> W� f y fiY <br /> 71M 01Dnp-20 <br /> ✓<GUlcafimM '_ I <br />