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LIQUID WASTE PERI``TT <br /> J JOAQUIN COUNTY PUJ3LIC HEALTH SERVICES ENVIRONW ,L HEALTH DIVISION <br /> 304 E.WEBER AVE 3ND FLOOR,STOCKTON,CA 95201 lei))468-3420 <br /> 1 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 103 O�f (',�/�Iy F ?D APN 'a /7-0 PARCEL SIZE: <br /> CITY/ZIP �Q Q(iT _ 15372 BUILDING PERMIT# <br /> OWNERNAME ADDRESS 103 0A L-Il2W E 2 72-D <br /> CITY/ZIPS�CIVtre kS_ Aa>04 PHONE NUMBER e� J� J Z <br /> CONTRACTOR Kb �J __3 A SC4 ADDRESS G ij I-1J <br /> CITY/ZIP riDDZ C�4 , PHONE NUMBER ( '209) 31,7 <br /> GEOGRAPHICAL INFORMATION: COORDINATES: x Y TOWNSHIP RANGE SECTION <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> ❑ NEW INSTALLATION ❑ RESIDENCE NUMBER OF BEDROOMS: <br /> ❑ REPAIR/ADDITION ❑ COMMERCIAL <br /> O DESTRUCTION ❑ OTHER <br /> NUMBER OF EMPLOYEES: <br /> ❑ ENGINEERED/ALTERNATIVE <br /> CHARACTER OF SOIL TO DEPTH OF 31: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> Ilp PERC TEST(S) HOW MANY APPLICATION# <br /> '❑` SEPTIC TANK TYPE/MFG_ CAPACITY #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY #OF COMPARTMENTS <br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> Cl LIFT STATION SIZE TYPE OF PUMr SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINE #OF LINES: LENGTH OF LINES: DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> INFLITRATOR CHAMBERS: <br /> ❑ FILTER BED WIDTH LENGTH DEPTH DI.STANCETONEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ,C <br /> ❑ SUMPS WIDTH LENGTH DEPTH DI.STANCETONEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ SEEPAGE PITS # DIAMETER DEPTH DISTANCE TO NEAREST: 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 24 HOUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)468-3423 <br /> SIGNED: Gt/, TITLE: G/E[ n DATE: 4572 <br /> n <br /> i <br /> i <br /> Ot <br /> J r <br /> fil Me CA -m <br /> 6• <br /> _...... <br /> •. <br /> b Y <br /> DEPARTMENT'USE ONLY <br /> APPLICATION ACCEPTED BY:---+C�/ AT L3I` AREA � EMPLOY E ID# DISTRICT LOCATION <br /> C + C <br /> INSPECTED BY: DATE: PERMIT fINAL�ES DAT*4ellSPECTOR-/ <br /> COMMENTS: � �� w <br /> PE CODE SC INFO AMOUNT CHEC CASH RECEIVED DA I E PERMIT/SERVICE REQUEST# INVOICE# SEPTIC IDN <br /> EMITTED BY <br /> z 1 J 79 Flo( 3) <br /> REVISED R-IS-01 <br />