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LIQUID WASTE PERMIT <br /> SAN JOAQL:M COUNTY FCDLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 30+E.W E'DFII AVE 3P•'FLOOR,STOCXTON.CA 05207(200)AAM.U20 <br /> JOB AUDKGI'9_�- 4� 3 N Q REFUNDABLE PERMIT EXPIRES I �R'FRO;'�C ISSL EDA <br /> A►N f,? , _a PARCEL 5171-_ <br /> CrnfzirILDINC.rOC 1C'rOR/ Q 'jd'� PTRMR I <br /> OWNFRNAME -_._- <br /> CIT.nq_ ?rOLJ�TOrI qS�O?� PHONE NU.MBL:H__ —_ <br /> CONTRACTOR DoN Cu /S1 NF-J /�j ADDRESS P•O•$�Ox 379�i <br /> CfTYZ► ! (21 �l�rs '� PHONE NUMBER <br /> GEOGRAPHICALINFORMATION:COORD(NATFS'kY' _- _ TOWNSHIP __—RANGE SFCTW)N <br /> TYPE.OF SEPTIC WORK: INSTAIJ.ATION WILL SERVE: NUMBER OF LIVING UMTS:— <br /> ❑ NEW INSTALLATION ❑ KESIDENCF V UMBER OF BEDROOMS: <br /> ❑ REPAIIUADDITION ❑ COMMERCIAL <br /> \UMBL'N OF EMPLOYEES: <br /> ❑ DESTRUCTION ❑ OTIIER _ <br /> ❑ ENGINEEREDIALTERNATIVF <br /> CHARACTER OF SOIL TO DEPTH OF 3•: PFTISUMP SOIL CHARACTER: WATER TABLE DErnI: <br /> rINCTEST(S) HOW MANY I_ APPLICATDUN/ <br /> ❑ SFPTIC.TANK IYPE'MFG - CAPACTTY BOFCOMPARTMENTS fel <br /> ❑ GREASE TRAP TYPF.;MFG CAPACITY - MOFCOMPARTMFNTS .W <br /> ❑ PKCTX PLANT UISTANCC TO NEAREST: ROLL F(xINUATION PROPERTY LINE <br /> ❑ LIFT TTATION 517F. TTPE M P.W. SAND OIL SEPARATOR(ENCLOSED SYSTEM) W <br /> Z <br /> ❑ LEACH LINE. M OF LINES'. LENGTH OF LINES: IRFT WLTONR+RGtT: WELL FOVNDAT)04 PROPERTY LINT <br /> INFLI I HAIOR CHAMBERS: <br /> ❑ FILTER BTL -.rN LENGTH DEPTH__ RMUK[TO.YIMDII: WELL FOUNDATION__-- PROPERTY LINE r <br /> ❑ W UP40ED WIDTH LENGTH DEPTH DIFTAMR TO VA+ACtT: WELL_ FOUNDATION PROPERTY I INE <br /> a <br /> ❑ SUMPS WIDTH LENGTH DEPTH wnANfF TD MRARtfi: WELL POLNOATIOn PROPERTY UNE <br /> ❑ DISPOSAL PONDS YIUTH.-, LFVCTII DETTH Ol]T+M4TOwR[m WELL FOUNDATION_ _ PROPERTY UNr l_ <br /> ❑ SEEPAGE PITS R DIAMI-,tRDEPTHoff W11D•1A•M WELL FM:NOATION PRWFRTV LINE Ai <br /> I N[RT.BY CERTIFY THAT t MAV[►REPARCUTMS APNJCATION AND THE WORK WILL BC DONE IN ACCORDANCE MttN SAN KIAQl11N COUNTY OROINANC LS.STAT[IAw3 <br /> �\ <br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)469-3 73 <br /> J <br /> SIGNED: �f 1 <br /> TITLE:eI✓NER DATE: / 17-R:72 <br /> [l <br /> - <br /> I <br /> * � I <br /> DEPARTMEN'T1 US/EIONLY 99 <br /> APPLKATON ACCEPTED BY.�!P-� _. DANT--._ ARFAEMPLOYEE IDF� •!OISTILIf7 LOCATON <br /> INB►iKTF.D BY .. DATE_- _ PFRAIIT FINAL YES DATE._ <br /> COMMENTS._- <br /> KCODE ]C:KO MIMINT ( 11 l]fEIVLJ D+tE PERMITIA. 'ICF.RF.0.41TE InvOKG ]ERIC mI <br /> LMII•rD SY <br /> REvatD A.I y l <br />