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,. .� LIQUID WASTE PERMIT <br /> • "r" r.w SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> i <br /> 304 E.WEBER AVE.,3A0 FLOOR,STOCKTON,CA 93202 (209)46&3310 24 H R N UTI C <br /> N NABLE PERM4 F4PIRF 1 YEAR FROM DATE ISSED REQI,lESTEI> <br /> JOBADDRESS {om•O FOR ALL <br /> INSPECTION <br /> C1TYiLIP �•— (/PAS/RCEL SIZFJAPN <br /> OWNER NAME�11�Sc�i C�IY1Ll,•I�IYL S ADDRESS fY,T <br /> CITYraIP_ !912R42 PHONE r <br /> CONTRACTOR G` ADDRESS#4D lu• f r-57� W <br /> CITY)ZIP........' 'J U�'1 JL•tJr _ PHONE_ 14(X&9_9&0 C <br /> GEOGRAPHICALINFORMATION:COORDIANTES: X Y TOWNSHIP__RANGE_SECTION__ <br /> PERC TEST(S)( )HOW MANY APPLICATION 0: <br /> TYPE OF SEPTIC WORK: ❑ NEWINSTALLATION ❑ REPAIRIADDIT[ON DESTRUCHON <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER— <br /> NIJMBEROFLIVING 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 TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENT'S <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 OP LINES / INFILTRATOR CHAMBERS <br /> DISTANCETO NEAREST: WELL FOUNDAIION _PROPERTY LINE <br /> Cl FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE':O NEAREST: WELL FOUNDATION:_ PROPERTYLINE <br /> ❑MOUNDED WIDTH LENGTH_ DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PIIS 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 DF_Pm _ <br /> DISTANCE TO NEAR EST: WELL - _FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE HONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY w <br /> ORDIANCES,SPATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: TITLE:, DATE: <br /> Zl­ <br /> � C <br /> n0 <br /> 'd..FAt Y, vi, _ <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: ATE: <br /> TANK PIT,OR SUMP INSPECTED Y:_ <br /> FINAL SNSPTaCT10N{I,Y;. csf�X�L -' <br /> COMMUNTS: <br /> PF.CODE SC AMOUNT RECEIVED BY DATE PERM fT/SERVLCE REQUEST h SEPTIC IDN <br /> INFO R1MLTMD SH <br /> z z2 ' <br />