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..� ti./ <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 PERMIT EXPIRES <br /> .1..YEAR FROM DATE ISSUED <br /> JOB ADDRESS `� . C 1 <br /> CITY/ZIP ^` t PA[RRCELSIZE/APN //lry�� ocrL 60­0.7 <br /> 1CStvf� U _� � -ADDRESS— <br /> SA <br /> DDRESS <br /> NAME_ 2 (� <br /> CITYIZIP ^ 77 f PHONE_ <br /> CONTRACTOR Y>t -F^ ADDRESS <br /> CITY/ZIP �lsl�(r (" I, �J PHONE r?oq -s67~JX_)/ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGESECTION <br /> PERC TEST(S) ( ) HOW MANY I - APPLICATION#: <br /> TYPE OF SEPTIC WORK: 01 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL _X�-0THFR �"C- <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 tTNE i <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) R E OF 1\!E I <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION !'ROPERTY LINE <br /> 1.;t)UfJ <br /> 11 FILTER JUAvUu'd FILTER BED WIDTI4 LENGTH DEPTH ��fpIqqC�� <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPER 'Li �� <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 /> ❑SUNIPS 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 THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY�7 <br /> ORDIANCF TAT' AWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. ��..yy��.� T <br /> SIGNED ,4 TITLE:J�IMJ DATE:3 <br /> V. <br /> �y <br /> `I <br /> S <br /> 5 <br /> w <br /> Ail <br /> ,p <br /> Off YNIt DEP ENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: �j - y� <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE: <br /> FINAL fj7jjl B)� <br /> COMMENTS: P. <br /> PE CODE SC AMOUNT CHECK#/ RECEIVED BY DATE PERMIT E ICE T# SEPTIC ID# <br /> INFO REMITTED CASH <br /> l <br />