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LIQU` WASTE PERMIT <br /> ` SAN JOAQUIN COUNTY PUBL LTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3R,STOCKTON.CA 95202 (209)468-3420 24 "R <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1. j:Z,l rr ,L 0(4 TF 9 S F�S7" R96 Tl-4(.r PV. F��7 t� ,�.LL <br /> r CITY2IP 1 1 1 44 PARCEL SIZE/APN /D fI C R)J' ^7 o ' OR <br /> OWNER NAME 7A AJ DLI f C yr5r1 ADDRESS �.C�. [���( I(TT)-4 <br /> CITY/ZIP tA T'l,I'J�/ u I QCC-)F�y- �S%>Cl I{!�� , PHONE �7�n 7 � /%L��� � ) <br /> CONTRACTORA[f/ U. /i/l.��l �G i' A�JyI. /Irl' ADDRESS 44' Al /7ly Sr7lt.)y A/ . <br /> CITY/IJP4.)V%l SsZ-�/a PHONED y) 39 26�-?J7J <br /> GEOGRAPHICAL INFORMATION:COORDIANTES: X Y TOWNSHIP_RANGE---SECTION <br /> PERC TEST(S)( )HOW MANY _ APPLICATION M: <br /> TYPE OF SEPTIC WORK: 'r NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL i1 OTHER_:Sj� f-r-L <br /> NUMBER OF LIVING UNITS: NUMBER OFBEDROOMS:— NUMBER OF EMPLOYEES:— <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTICTANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG 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 CHAMBERSP l <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE PffiN-1 <br /> ❑FILTER BED WIDTH LENGTH DEPTH RECEIVED <br /> _ DISTANCETO NEAREST:WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH MAR 12 2001 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LSW�TU0A=N'COUNTY <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH SPAUFB�LIICC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I � <br /> ❑SUMPS WIDTH LENGTH DEPTH - <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEFTH <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 /> ORDIANCE/�,$(,TATE LAWS,/AJND�{UfI ES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> — SIGNED: ' bbl 6%j��/� TIILE: LE L r) C%� DATE: / <br /> r'. ,c'jl O . <br /> 't <br /> q <br /> :J------ <br /> I v 11 1 1 zl� <br /> Ali I <br /> III 1 1"111 1 it <br /> I <br /> i S 2 <br /> .� A L O D <br /> I <br /> ��� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: 'W1��1 I1��1f(Art ^• DATF-' Z <br /> TANK,PIT,OR SUMP INSPECTED BY: -DATE' <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PECODESC AMOUNT CHECK II/ RECEIVEDBY DATE PERMIT/SERVICE REQUEST x SEPTIC IDN <br /> INFO REMRTE CASH <br />