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)r-- *.e 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 _J c <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSf7..�1>t/f <br /> CITY/ZIP� 1 l._f'l �S�rC - PARCEL SI7.IFJA__P1N� <br /> OWNER NAME AC k-r' �c Ao� ADDRESS f�'C� o,_/�cTT1L'��1t.�-- <br /> CITY/ZIP <br /> PHONE <br /> CONTRACT/OR' p /`I elfy�Tn� /] r M / <br /> ADDRESS ZS ZS E _ rfl, <br /> CITY/ZIP i ! v`� PHONE_ ZUG-44S'134 S <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGESECTION <br /> PERC TEST(S) (<HOW MANY 1 APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL OTHER i <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: '23 <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPEIMFG 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 /> PAY i\,l; <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS R Frit :It/ <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> _-� 1=O'ill F,i;;i•.,.t: ir, i;i it" ; ., <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 (-N <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 <br /> ORDIANCES STATE LAW' D LES AND REGULATIONS OF SAN JOAQUIN COUNTY. ry. <br /> SIGNED:_ f��i �^ TITLE: A?t �Y1a1/�Cif DATE:DQ-IO'DI <br /> ( o.bs,ls <br /> (olla'1.1,� q <br /> < a I _ • . <br /> w� <br /> -- " - rTrr K• <br /> O�_ I ISI �•=��ll 1~I 1 1 1 1 1 1 �011aillf. .L'� Y' <br /> \ J \ -- � -� •L 1 1 1 I^I � � - 1D' <br /> i <br /> 1 <br /> FOR DEPARTMENT USE ONLY ] <br /> DATE: <br /> APPLICATION ACCEPTED BY: <br /> 1 <br /> D _ <br /> TANK,PIT,OR SUMP INSPECTED BY: <br /> 4 <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PE CODE SC AMOUNT HECK N RECEIVED BY DATE PERMIT/SERVICE REQUEST N SEPTIC IDN / <br /> INFO REMITTED <br /> F' ., <br />