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LIQUIDWASZ` O <br /> 'ERMIT S <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESNVJRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE..3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 214 <br /> /J NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRODATE ISSUED <br /> JOB ADDRESS / /V G/ 4 (D- - <br /> �rs <br /> CITYMP PARCEL SIZE/APN > <br /> OWNER NAME / �}✓� ADDRESS 7�7` 6c* <br /> CITY/ZIP C PHONE S!-y/-7- .5 <br /> CONTRACTOR ADDRESS <br /> CITY/ZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECI'ION <br /> PERC TFST(S)(( )HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: P9,[ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: �I❑"RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> a <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER; WATER TABLE DEPTH <br /> SEPTIC TANK/GREASE TRAP TYPF(MFGFl� _e <br /> CAPACITY �lOpo MBER OF COMPARTMENT <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FQUNDATION f�PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SQA/N^D�OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING LINE NUMBER&LENGTH OF LINES __� / `�I V ( rINFILTRATOR CHAMBERS I <br /> DISTANCE TO NEAREST:�WELL_ FOUNDATION�,�oROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST:WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> ��/1 DISTANC TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> gl'SEEPAGE PITS WIDTHS L ' DEPTH I <br /> 1/" DISTANCE TO NEAREST: WELL FOUNDATION d�PROPERTY LINE 7 47S <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE / <br /> I HEREBY CERTIFY THAT 1 AVE PREPARED TRIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> >/— ORDIANCES,STATE Lg ,AND R{JtFS AND REGULATIONS OF SAN JOAQUIN COUNTY. �r7 / Q <br /> SIGNED: // /�; .. TITLE:(/L!f/ —<- 'DATE:All7_ <br /> i C <br /> I <br /> P <br /> I <br /> T JEALT <br /> v Hk I S <br /> Xzi <br /> �7S <br /> # <br /> 1 7 C*D�a�/0 <br /> FOR DEP T NT USE ONLY <br /> APPL/ICATION ACCEPTED BY: P. DATE: <br /> A,RJ, d_' <br /> OR SUMP INSPECTED BY: DATE: v _ <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PE CODESC AMOUNT CHEC RECEIVED BY DATE PERMfI'/SERVICE REQUEST# SEPTIC ID# <br /> INFO REMITTED H <br /> z it oDg q D I <br />