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LIQ WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBL ALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E WEBER AVE.,3° FLOOR,STOCKTON,CA 95202 (209),168-3420 24 HR M _-T D <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED R E Ct U 1l v- T�`rD <br /> 11C{c� �. k(XiC 111 .1�/,� _Q CC1"' �y^� ; �t FIG;R /NLL <br /> JOB ADDRESS ��� ��3 ' 'L Yl ��"� � <br /> CITYrzU` PARCELSIIFJAPN C <br /> TNAME t!CIYf L !i `w sa 4 ADDRESS I(V�7 <br /> CITY/'LIP , "CIA* � PHONE <br /> CONTR.CTOR �1E ,L�.� �,Enp��� N/ of-_. ADDRESS �U�VA�L>✓1 <br /> CfIYrLIP LL lz. /pp•f' q col L� PHONE \�!-32 <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP___RANGE_SECTION <br /> PERC TEST(S)( )HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: 091-NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL OTHER �rinf,! <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 TABUS DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS - <br /> ❑PKG TREATMENT PLANT �.. DISTANCE TO NEAREST: WELL FOUNDATION- PROPERLY, <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) MAR M''"''"�1SSSSII l� <br /> r ❑LEACHING LINE NUMBER&LENGTH OF LINES ! INFILTRATOR CHAMBERS 6 2009 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> SANJOAQUW-COU19TY <br /> ❑FILTER BED WIDTH LENGTH DEPTH PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> .r DISTANCE TO NEAREST:WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION 4 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 UNE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN '$�`TATTEELAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. / <br /> SIGNED rlr�' C O TTTLE:&& DATE: <br /> \�1 <br /> Az <br /> r <br /> v <br /> v � - <br /> t <br /> FOR DEPrI PENT USB ONLY <br /> rAPPLICATIONACCEMDSY: {jl� DATER,OR SUMP INSPECTED BY: DATESPECTION BY: <br /> COMMBHTS: <br /> DECODE SC AMOUNT CHECK#/ RECEIVED BY DATE PERNIMSERVICE REQUEST II SEPTIC IDN <br /> INFO REMRTED CASH <br /> 97 4 5Ei <br />