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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEAL"I H SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E.WEBER AVE.,3PD FLOOR,STOCKTON,CA 95202 (209)466-3420 <br /> NON•RE IYDABLE PERMIT EXPIRES I YEAR FROM DATE 11SUED <br /> JOB ADDRESS <br /> z,�z23 s. A ��,� �a R; cam . 9535 � �•� .-s.� <br /> Q�^ - <br /> �� PARCEL SIZF7APN <br /> NAME ADDRESS L��+— {�Q- •`.s:',{�:;-•-�-'l.__)I�`. S <br /> CTI {49 S 2 no 3 s. 1�►xsT t n �a . <br /> OWNER NAME q _ <br /> CITYrZIP 1'2\tx�n PHON a 1 -299 <br /> CONTRACTOR (]'ig �Y / C6IIN�4� ^"'>'1' Lor'1�ADDRESS t;L9S�►Q-� raL��ve <br /> CITYrl.IP � 75351 PHONE O-1,) <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP '_^,�RANGE_SECTION <br /> PERC TEST(S)><HOW MANY�_ APPLICATION N: r r`�_ <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 OFSOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASF.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&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION ?ROPERTYLINE <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 /> 1 HERE Y CERTI Y T T 1 HAVE.PREPARED THIS APPLICATION AND THF.WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN STA E LA S, 'D RULES AND REGULATIONS OF SAF JOAQUIN COUNTY. t/111 P <br /> SIGNED: �Pr� TITLE If E^'Ii� +L°j�� DATE:— <br /> Ole 0 0 ol* a o Ole <br /> ATE:• le00ot• • • •l• e •E• • <br /> • • • A M • • • • • • • • • • I I A <br /> • • • PARCEL 2 • • • • • • PARCa 1 <br /> • <br /> t _ <br /> • • • • • O • • O • • � • y <br /> 00 �� <br /> e��► • • • e • • • • � • • • a ....,.. Ti <br /> III- <br /> o <br /> SNS \ ` & 1 RDI RTMENT EONLY <br /> APPLICATION ACCEPTED BY'. U DATE' <br /> TANK PIT.OR SUMP INSPECTED BY: DATE' <br /> FINAL INSPECTION BY:_ <br /> COMMENTS: <br /> PECODE SC AMOUNT F¢CK RECEIVED BY DATE PERNIMSERVICE REQUEST M SEPTIC IDM <br /> O RtMITTED H <br />