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E <br /> LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E WEBER AVE..30.0 FLOOR.STOCKTON.CA 95202 (209)468.3420 2-1- <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED R E(D u I=-".�. �-_- <br /> JOB ADDRESS �.3�--�3 <br /> PARCEL SIZWAPN <br /> pRNAMFyC�Yla9 ADDRESS00 <br /> 232039 5 I�uST`n '6Za <br /> TAPTEW <br /> CITYIZIP lg\W YI PHONEUa <br /> CONTRO ��arat CA'I"vTYQ"L_XLn <br /> �LOr*jS�'e_ADDRESS (019-5 N -EwratiPAve, t5LQG, <br /> CITY/ZIP W�4puv-,� 75377,1 PHON IOR) 52.q,401 <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP_RANGE___$ECTION <br /> PERT TEST(\ HOW MANY_, _ APPLICATION <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES:— <br /> CHARACTER <br /> MPLOYEES:_CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER d LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <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 HEREY CERTI T T I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN STA LA S, D RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. t „I r 8 f Q <br /> SIGNED: oe TITLEY�' �'�a��'+E'�� DATE: JJ <br /> V'J <br /> sN.,v A,�,I A••�R I— <br /> momw <br /> i * f• w * 019 • • •�• • •1* • <br /> • • • ® * • • 0 • • • • • * • I <br /> 0000 • • • • • • • a • • • • I _r \ <br /> • • • • • • • • • • • * • ♦ • ' I <br /> • • • PARCEL 2 • • • • • PARCEL 1 1 <br /> 0 <br /> • 00 . 00 • * • .• • • • i _0 ` <br /> •,* • • • • • • • • * • • • <br /> �a <br /> mahw, <br /> 0 <br /> FT F <br /> �--iOIt DEPARTMENT E ONLY <br /> APPLICATION ACCEPIBD BY: V• j G t -l DATE: <br /> TANK.PIT.OR SUMP INSPECTED BY: ATE: <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PECODE SC AMOUNTHECK RECEIVED BY DATE PERMTf/SERVICE REQUEST N SEPTIC MN <br /> �:�� ! ITTEo <br />