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LIQUID WASTE PERMIT <br /> SAN JOAQUIN'lJOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HE6,4DIVISION 24 F-6 yam- �g�y-P-' .E <br /> 304E.WEBER AVE..3RO FLOOR,STOCKTON,CA 95202 (209)46R+3420 REQUEST p <br /> NO -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE�ISSUED FOR A L L <br /> TOB ADDRESS �� Z Ge/e INSPECT <br /> y <br /> S <br /> PARCEL SIZFAPN CITY/LIP In3gG T 4 - -0p <br /> OWNER NAME ADDRESS I /7 � " ��[ � /DO <br /> CITY/ZI44Z� <br /> / C.4 3-7 PHONE ezd-7-) 72 7 "' '/97/n7/4 <br /> CONTRACTOR y- I ADDRESS /�'z`� \7O �KL K�* ��f4 y <br /> CITY/71P �1 RAPHIC�A FORMATION�COORDA X` PHONE TO CILSI 727— 57: 7 <br /> /'.VI+t ilw V � ��jj �/ <br /> 79ECTIONI,3 <br /> PERC TESTIS) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION �TRUCTION <br /> INSTALLATION WILL SERVE: 13 RESIDENCE ❑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 CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PRO 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 PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL FOUNDATION: PROPERTYLINE <br /> ❑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 NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY T I HAVE PREPA D THIS eyPP t TION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN Co <br /> ORDIANCES,STATE 1 !AND RULES EG LA S OF SAN JOAQUIN COUNTY. jJ'�fj/ <br /> .�� SIGNED: TITLE:_!-H�i./- DATE: <br /> i <br /> f <br /> M � <br /> FOR DEPARTMENT USE OMJ <br /> APPLICATION ACCEPTED BY: T� DATE <br /> FINAL INSPECTION BY: = _ rOUliI <br /> COMMENTS: <br /> PE CODE SC AMOUNT FSC RECEIVED BY DATE PERmffSERvIcEpzQmT# SEPTIC IDR <br /> MPo <br /> BE <br /> DSH <br /> 3 <br /> 1 <br />