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C LIQUID WASTE PERMIT�) <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTHDIVISION <br /> 304 E.WEBER AVE.,3A°FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-REFUNDARLF PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS . <br /> CITYIZIP !'ARCELSIZEJAYN <br /> OWNER NAME ADDRESS Aw► <br /> CITYIZI P PHONE <br /> CONTRACTOR ALA-- �Cb ' • .ADDRESS . 5 .Lk) <br /> C[TYIZTP PHONE {7 <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGESECITON <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> I <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION TRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE 0 COMMERICIAL 0 OTHER iy <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:— <br /> CHARACTER <br /> MPLOYEES:CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEP'I7C TANK/GREASE TRAP TYPEIMFG CAPACITY NUMBER OF COMPARTMEN'T'S <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 0 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 w <br /> ❑FILTER DED WIDTH LENG'T'H DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH [ �I <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPFRTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE" <br /> ❑SUNIPS 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 /> 1 HE CERTI' THAT I f VE PREPARED TRIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITII SAN JOAQUIN COUNTY / <br /> ORDIANC' A A S,A R E D REGULATIONS OF SAN JOAQUIN COUNTY. C <br /> S1GNE }} TITLE:' DATE: <br /> 1 -4 <br /> s <br /> i <br /> l � 5 <br /> I <br /> i <br /> i <br /> 1 <br /> I <br /> F� <br /> •�`( X11 , <br /> Ir IFA�4i`,fi� ,,, -��,• <br /> R N4�(' a <br /> FOR�DEPARTMF-NT USE ONLY <br /> APPLICATION ACCEPFEDBY:_ ` yyV�W� l✓"'- �� _._ DA.f.E,.' <br /> SANK,IIT,OR SUMP INSPECTED pY: DATE: <br /> r FINAL INSPECTION BY: r!l L7 <br /> COMMENTS: It-(7- <br /> �1 PE CODE SC A gUNT CNECIC N! RECEIVED BY <br /> DATE PERM1T15ERV]CP REQUEST# SEPTIC]Un i <br /> INFO REMITTED <br /> -2/ 5j2- <br /> F <br />