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i <br /> ..,,,.. <br /> LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENVIRONMENTAL HEALTH DIVISION <br /> ' 3M E.WEBER AVE.,S FLOOR,STOCKTON,CA 93202 (2U9)468-3420 24 HR N OTI C: <br /> N NDAII-PE PI F IY DATE IS REC)UESTEC <br /> JOB ADDRESS a o FFC3 R A l.._L. <br /> INSPEC;TYC3N <br /> CFI'Y2.IP RCEL SIIFIAPN <br /> OWNER NAME110 5SFcaa 5 ADDRESS- <br /> arytIIP_ N� PHONE <br /> i CONTRACTOR 4 f -mv5 ADDRESS/LIfiU <br /> CTTY/ZIP— _ 'TU�'I .. �.S � PHONE_. o4te cl 60 7 _r <br /> GEOGRAPHICALINFORMATION:COOROIANTFS: X Y TOWNSHIP---RANGE—SECTION <br /> PERCTEST(S)( )HOWMANY _ APPLICATION N: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE: ❑COMMFRICIAL ❑OTHER_ <br /> NUMBER OF LIVINO UNITS:_— NUMBER OF BEDROOMS:, NUMBEROFL•MPIAYEFS:_ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FFJlr-. PI17SUMPSOILCHARACTER: _ WATER TABLE DEPTH <br /> ❑SEPTIC TANWRFASE TRAP TYPE/MFG __CAPACITY NUMBER OFCOMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCETO NEAREST: WELL FOUNDATION _ PROPERTY LINE <br /> ❑LIFT STATION SIZE-- TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACIIINGLINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DI.STANCFTONEARES'T: WELL ' FOUNDA'ITON —PROPERTYUNE <br /> ❑FILTER BED WIDTH LENGPH DEPTH —._ <br /> DISTANCETO NEAREST:WM.L FOUNDATION:_ PROPERTY LINE <br /> ❑MOUNDED WIDTH_ LENGTH_ DEPTH <br /> DISTANCE To NT.AREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PIIS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOINUATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 13 DISPOSAL PONDS WID17i LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HA VR PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY W <br /> ORDIANCES,STATE LA WS,AND RUES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED TITLE:, DATE: <br /> ol <br /> n <br /> - _ <br /> i <br /> h <br /> -( <br /> -- - - - --- 1..F.AiTV, _ <br /> FOR DEPARTMENT USE ONLY <br /> APPIJG'DON ACY:6Y1'FD HY:, � DATE:I ts� <br /> TANK,PIT.OR SUMP INS`PECrED Y:. _DATE: <br /> FINAL 1NSPf>CTION IIY; �i1 _-- <br /> COM&T-iT3: <br /> PE.'ODDE �FSCAINIOUT RECENED BY DATE PERMD'/SERVKE REQUHM-T P SEPDC IDk <br /> "nTED (9 ,2-2-2-47 -� <br /> n ' <br />