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`. LIQUID WASTE PERMIT, <br /> SANT J. )IN COUNTY PUJ3LIC HEALTH SERVICES ENVIRONMENTAL t- -STH DIVISION <br /> --.1 04 E.WEBER AVE 3"'FLOOR,STOCKTON,CA 95202(209)469-5420 ac, <br /> f !, /! ] NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ISSUED <br /> JOADDRE55, • I�DOc/�,�1� APN��"—�S�'— PARCELSIZE <br /> CITYIZIOr 4 q5 110 BUILDING PERMIT q <br /> OWNER NAME✓� G�/I ADDRESS <br /> CITYIZIP_ ()h JT PHONE. NUMBER <br /> CONTRACTOR ADDRESS <br /> ' R �- 7,57C1TYlZiP _. D a � � �'� PHONE NUMBS I "..'...... .. —I_---_ <br /> GEOGRAPHICAL INFORMATION: COORDINATES: X Y TOWNSHIP RANGE SECTION <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS.- <br /> El <br /> NITS:❑ NEW INSTALLATION A RESIDENCE NUMBER OF BEDROOMS: -� <br /> I ❑ REPAIR/ADDITION O ❑ COMMERCIAL QQ <br /> NUMBER OF EMPLOYEES: <br /> 13 DESTRUCTION ElOTHER <br /> ❑ ENGINEEREDIALTE T 0 <br /> �CHARACTER()F.SOI I, DZ H 01,3': PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> Jlq <br /> PE RC TEST(8) HOW MANY APPLICATION# <br /> /❑ SEPTIC TANK TYPEIMFG_ CAPACITY #OF COMPARTMENTS Q <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY #OF COMPARTMENTS <br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I ❑ LEACH LINE #OF LINES: LENGTH OF LINES: DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> INFLITR ATORCHAMBERS: <br /> I <br /> ❑ <br /> FILTER BED WIDTH LENGTH DEPTH DISTANCE TONEAREs[: WELL FOUNDATION PROPERTY LINE <br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ SUMPS WIDTH LENGTH DEPTH DISTANCE TONEARV;T: WELL FOUNDATION PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCE TONEARHST: WELL FOUNDATION PROPERTY LINE <br /> ❑ SEEPAGE PITS # DIAMETER DEPTH DISTANCETONEAREST: 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 ORDINANCES,STATE LAWS <br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> INIMUM 4 HOUR ADVAN T.ICE REQUIRED FOR INISPECTIONS–PLEASE CALL(209)468-3423 <br /> SIGNED: TITLE: 01 L DATE: 9—13 D2r— <br /> .-...._.,..,..-.y. I ....I................. ........ .....' <br /> Ii AA <br /> � I I <br /> II .4-1 <br /> ..._ _ <br /> i <br /> ,.. <br /> f �ir E I I j I --I , I _-_ � _ � <br /> I E �.......L . 1f_ I I_, i,,, ; • I I _ _ E ., .. I„ <br /> { <br /> { � . <br /> i. ... <br /> PAYP41ENT.. <br /> E I - - ' <br /> - 3 <br /> a hag. <br /> al ' . fi AN�JOAOU N OUIJTY I ..,..,. <br /> l p y �SIBLIC HEAL FI #VIES 111 <br /> -- - <br /> ........... <br /> MEPIFIIE <br /> Elf <br /> DEPARTMENT UNEONLY <br /> APPLICATION ACCEPTED BY: V 4}� DATE: 16 f " +�AREA I f MPLOYEE ID# I DISTRICTLOCATION <br /> a <br /> INSPECTED BY: �IeV S _ _DATE: �2— PFRMIT FINAL Q YES DATE: INSPECTOR: <br /> COMMENTS: �G�/..aHOts'bl <br /> PE CODE SC INFO AMOUNT ECKk! SH RECEIVED DATE PERMITISURVICE REQUEST# INVOICE# SEPTIC 1W <br /> REMITTED I BY <br /> I'll /7 S 00 312 <br /> E <br />{fi REVISED x.15-01 <br /> L_ <br />