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r.r LIQUID WASTE PERMIT�� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IiEALTH DIVISION,.._ <br /> 304 E.WEBER AVE.,3'D FLOOR,STOCKTON,CA 95202 (209)468-3420 - <br /> / 'J NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS�J <br /> CITY/ZIP PARCEL SIMAPN <br /> OWNER NAME G ADDRESS f?UdJ /+/-cj <br /> CITY/ZIP PHONE <br /> CONTRACTOR e /J /• `C ADDRESS ��/U� /�!/'.A.J✓•C-� C/'� <br /> CITY/ZIP 4� �� "l/ � PHONE �! ; f <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGESECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE 49'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 TANK/GREASE TRAP TYPFJMFG /( C,2AX/ff!S. CAPACITY2 ^ L&)O NUMBER OF COMPARTMENTS <br /> f f <br /> ❑PRO TREATMENT PLANT DISTANCE TO NEAREST: WELL Qs FOUNDATION /rZ 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 /> 3� 1 DISTANCETO7T: WELL FOUNDATION: PROPERTY LINE <br /> 41 MOUNDED WIDTH <br /> LENGTH DEPTH 1/2 y <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH - <br /> DISTANCETONEAREST: 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 K W ILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE/LS,AND RULES AND REGU &6FSJCI�JOAQUIN COUN'T'Y. <br /> SIGNED: /! TITLE: aTw-4� � DATE: <br /> c7 <br /> ---------- --0 ------- ------ <br /> t—— ———— ———— <br /> N (, <br /> / FORDEPARTMENT USE r` <br /> APPLICATION ACCEPTED BY: RECEIVE D DATE: 41 - <br /> TANK,PIP.ORSUMPINSP BY DATE' <br /> HNAL INSPE ON BY: /- • <br /> J-14, uu 1_ F2Rw 16"A !Lb F rr�v - got ria N DdR )I�(5 <br /> COMMENTS. <br /> 1 E V /-jf•o/ Q If TF <br /> po <br /> PE CODE SC AM NT C MI RECEIVED BY DATE PERMRISERV UESTp SEPTIC 1D <br /> INFO REM <br /> H114 zso sari 2� 3 � s-- <br />