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LIQUID WASTE PERMIT ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIO <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3424 <br /> �i-. <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> !OB ADDRESS ' 607A, <br /> CITY/Zip j�o—n PARCEL SIZFJAPN 7 ! <br /> OWNER NAME }/ t✓ r 1 ADDRESS r . <br /> CITYMP r �~ O PHONE <br /> CONTRACTOR ADDRESS <br /> CITYIZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNS HIPRANGE SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION XDESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANKIGREASE 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 PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCETO 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 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN STATE WS,AND ULES N GULATION5 OF SAN JOAQUIN COUNTY. �/p <br /> SIGNED: ` TITLEDATE: <br /> 1 1+1 1 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: L +^� pp __,�, J `I DATE: 3 <br /> ,• <br /> TANK,PIT,OR SUMP INSPECTED BY: A-,-e O F ,6 Sol I4 DATE fO aV O� <br /> 1 ALINSPECTION BY: <br /> CO <br /> MNTS: L Sl <br /> IFHIfi d jYLii�1 ... •SF 1 <br /> T' PE CODE Sc AMOUNT CHECK 01 RECEIVED BY DATE PERMTTlSERVICE REQUEST# SEPTIC ID# <br /> {�I- INFO l_MrFfrnD CASH <br /> 6"437 6 5r� gay <br /> z66/ <br />