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LIQUID WASTE PERMS �® <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> !� JOBADDRESS <br /> 304 E.WEBER AVE 3m'FLOOR,STOCKTON,CA 95202(209)469-3420INON-II�FUND E PE IT EXPIRES I YEEARR]FRO/M DDA�TE ISSUED`'� rT C <br /> C/�. /^K..1-fAiE11J{ [ 'Lf/-I�r_C1O_(�0A PARCEL SIZE:; <br /> CITY/ZIP BUILDING PERMIT N /I <br /> r OWNER NAME �F11 lG ADDRESS /VA <br /> CITY/ZIP J1� PHONE rN-UUMMBBER 1 - n <br /> �.. CONTRACTOR /Vko ADDRESS LJ�.. �t (0 I^(1�,(/n&9C O <br /> CITY/ZIP PHONE NUMBER q g ``VL V (4 y <br /> - GEOGRAPHICAL INFORMATION: COORDINATES: X Y TOWNSHIP—RANGE—SECTION- <br /> TV <br /> OWNSHIP RANGE SECTION <br /> STV E OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> p�NEW INSTALLATION El RESIDENCE NUMBER OF BEDROOMS: <br /> �/❑ REPAIR/ADDITION ❑ COMMERCIAL <br /> NUMBER OF EMPLOYEES: <br /> ❑ DESTRUCTION A OTHER <br /> ❑ ENGINEERED/ALTERNATIVE <br /> CHARACTER OF SOIL TO DEPTH OF 311lAtIdAit, PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH:zop!9�I <br /> ❑ PERC TEST(S) HOW MANY­47- <br /> APPLICATION# <br /> SEPTIC TANK TYPE/MFG 5µJJGfGC I �I CAPACITY �.+5 a #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY #OFCOMPARTMENTS <br /> q f y <br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELLI b0 * FOUNDATIONS' PROPERTY LINE t 00 T <br /> �❑5 LIFT STATION SIZE TYPE OF PUMP �y SAND OIL SEPARATOR(ENCLOSED SYSTEM) s <br /> LEACH LINE #OFLINESVS <br /> `. LENGTH OF LINES: -0w DLWF ETONEARLO': WELL Iw /FOUNDATION Ems+ PROPERTY LINE <br /> INFLITRATOR CHAMBERS: <br /> ❑ FILTER BED WIDTH LENGTH DEPTH D14FANCE TO NFARLST: WELL FOUNDATION PROPERTY LINE <br /> r ❑ MOUNDED WIDTH LENGTH DEPTH_ DIST.NCETONEAREAF: WELL FOUNDATION PROPERTY LINE <br /> ❑ SUMPS WIDTH LENGTH DEPTH UISTANCETONEARE.4T: WELL FOUNDATION PROPERTY LINE <br /> R. ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH DLCFANCETONEABESF: WELL FOUNDATION <br /> 11 FOUNDATION PROPERTY LINE $0 <br /> SEEPAGE PITS #R DIAMETER1 DEPTH�J DM. ANCETONEARST: WELIM 4 FOUNDATION- PROPERTYLINE166 <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS <br /> r AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. 4 <br /> M 2 HOUR A NCE NOTICE REQUIRED FOR INSPECTIONS-PL $E CALL(209)/66-3/73 <br /> SIGNED: TITLE: DATE: Z�2(o-OL <br /> I - <br /> IRA <br /> I i �vNTWi�1— � +- --1—I-� <br /> — <br /> t t -; <br />