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r LIQUID WASTE PERTV.-2 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE„3R°FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> ON-REFUNDABLE,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -f�`X k I .: a-'R-� <br /> ED <br /> JOB ADDRESS <br /> cITrralP CFes. 9 52372PARCEL SIZE8 - a "' <br /> D Q J� 1� '�j'Z5- � <br /> OWNER NAME- C Gl71�S � �Ta� ADDRESS r I ' , 51 7-t <br /> CITYfZIP �SG�F l0/ '. �/ Z� PHONE e- jg J/ <br /> CONTRACTOR 1 r Oi./r{1.1 A.�y'' `fi`14raS�, ADDRESS Z-Z"•�TT`�`e <br /> CITY2IP t ' PHONE f0 <br /> I <br /> I GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP�RANGE SECTION <br /> I <br /> PERC TEST(S) ( ) HOW MANY�. APPLICATION#: r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION �a 70_ <br /> INSTALLATION WILL SERVE: RESIDENCE ❑COMMERICIALOTHER F--r-945:' A, <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: e If!gY CVPIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE 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 / c <br /> INFILTRATOR CHAMBERS r <br />! DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> C <br /> DISTANCE TO NEAREST: WELL FOUNDATION; PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH QI <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 /> ORDIANCES,STATE LAWS,AND RULES ONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: y <br /> �� � /J�] <br /> TITLF����"7' /"� �,vt DATE:�7� <br /> _ I t <br /> � (A*�, <br /> 1 y 1 <br /> r ! ars.rnr x-nwrtorr 1� <br /> � I <br /> x <br /> a rr <br /> w <br /> FO�R➢_ _ <br /> .p EPARTMFNT USE ONLY <br /> u <br /> I I I <br /> APPLICATION ACCEPTED BY: <br /> IDATE: <br /> OR SUMP INS P y; _ <br /> _- - - - _ • / <br /> FINAL INSPECTION BY; -DATE: <br /> �^- ��J •yam /�7 .�. i�y-y� - <br /> 1 <br /> PE CODE SC AMOUNT RECEIVED BY DATE <br /> INFO REMfITED ASH RERMIT/SERV[CEREQUEST# SEPTIC ID# <br /> I 72 <br /> I <br />