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l <br /> .� LIQUID WASTE PERMIT ...� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-REFUNDABLE P�ERM�IT EXPIRES <br /> IYEAR FROM DATE ISSUED <br /> Fmvi <br /> JOBADDRESS ` tqqd' -j �" <br /> CITY/ZIP PARCELSIZE/APN t ^oL`e M <br /> [/ �J ./ <br /> 6O D�� <br /> OWNE NAME ADDRESS P 62 130�� /'= <br /> CITY/ZIP PHONE -3 O !�_30_] N <br /> �� 1 ADDRESS � FbL,-0Uv.Lvl <br /> CONTRACTOR 7 �l /^/ <br /> CITY/ZIP (Lr�([r C" L J ✓ PHONE �q L "y/ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNS HI PRANGESECTION <br /> PERC TEST(S) ( ) HOW MANY I APPLICATION#: <br /> TYPE OF SEPTIC WORK: pl�NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL _,R�OTHER ScVoG 1 <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 TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY RAYRA F-I\I <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) R ECF►VE C.. <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS �l(!I? 3 �) ,/v <br /> AI, <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH 3AN JOAUUIN COUNT'(PUBI IC HEALTH SERVICES <br /> J1!�pr�r L <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERT�LE{3�I HFAITHDIVI.s0: <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 /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY 6,.`/ <br /> ORDIANCF� FTAT AWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. �.�¢� <br /> SIGN ED!(I �� - TITLE:( -� DATE: <br /> � �. <br /> � r0 <br /> \ V <br /> rtTt <br /> 1Lo \ <br /> w <br /> i <br /> � FFq( DE Pe ENT USE ONLY <br /> APPLICATION ACCEPTED BY: W"— DATE: <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE:- <br /> FINALI <br /> COMME S: hap f/� E7S R &).i <4.lr )e <br /> PECODE SC AMOUNT CHECK A/ RECEIVED BY DATE PERMIT'li 'ICE Q Tp SEPTIC IDM <br /> INFO REMITTED CASK <br />