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LIQUID WASTE PERMIT <br /> • %" SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> j 304 E.WEBER AVE.,Sao FLOOR,STOCKTON,CA 93202 (209)468-3420 24 H R N UTI C <br /> I NON•RFF ABLE PER P1RF YEA FRO 7 DATE ISSUED R EQ U ESTE 1) <br /> a �o FOC=I ALL <br /> JOB ADDRESS t N S P ECTi G N <br /> C1TYrL1P (f� P RCEL SIZEJAPN Q <br /> OWNER NAME_LU,15 DrY1 FCc.•!'m 5 ADDRESS,T�! e <br /> CITYIL[P_ �/ !jSl23142 HONE <br /> CONTRACTOR 4 E vS ADDRESA�OZ IY-907 <br /> W1��57� <br /> CITYfZIP t.1 "IUB =mow PHONE_ (X(O` 0 / <br /> GEOGRAPHICALINFORMATION:COORWANTES: X Y TOWNSHIP__iANGE_SECT[ON__ <br /> FERC TEST(S)( )HOW MANY APPLICATION 0: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL [10-1 HER_-... <br /> I NUMBER OF LIVING UNITS:__ NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES:,_ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: _ WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPEIMFG 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 __DROPERTY LINE <br /> Cl FILTER BED WIDTH LENGTH DEPTH _ <br /> DISTANCE70 NEAREST: WELL FOUNDATION:_ PROPERTY LINE <br /> E3 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 NLAREST: WELL FOUNDATION PROPERTY LINE " <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH _ <br /> DISTANCE TO NEAR FST: WELL _ —FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY W <br /> ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: TITLE:, DATE: <br /> 000 <br /> i !N <br /> 1 n�. <br /> 0 <br /> _ n <br /> P DI)VFf C U, f'r <br /> 'll• FAt <br /> t <br /> FOR DEPARTMENT LLSIi O_NT_Y <br /> ' APPLICATION ACrEPTED BY: <br /> TANK,PIT,OR SUMP INSPECTED Y'. .. DATE: <br /> FINAL INSPECTION Ul:;` j wq e <br /> COMMENTS: <br /> PECODE SC AMOUN! EC RECEIVED BY DATE PERM rr/SERVICE REQUEST• SEFmc IDR <br /> INFO RCMITTED SH <br /> z2 I <br />