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-01-03 <br /> LIQUID WASTE PERMIT <br /> SAN JOAQUiNCOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ,�ALTH DIVISION <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> iVON-REFUNDABLE ERMIT EXPIRES 1 YEAR OM DATE ISSUED t^ , -- —L— <br /> JOB ADDRESS K , �8 <br /> CITY/ZIP PARCEL SIZE/APN-C},-�� _T (loci — <br /> OWNER NAME grlslzs� ADDRESS7"�rl tll <br /> CITY/ZIP s?/� �/� ��C's .A^ _!/ PHONE <br /> CONTRACTOR���j1�L_—��Gy----l^C/ _ ADDRESS <br /> -----1-dirc_�- m= Uf <br /> C11Y/LII' <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGE_SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION M: OA TYPE OF SEPTIC WORK: EL NEW INSTALLATION ❑ REPAIRIADDITION C3DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE 9COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: .) <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET:l6y PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> [ISEPTIC TANKIGREASE TRAP TYPE/MFG 61&=. CAPACITY 1,6U[_l NUMBER OF COMPARTMENTS_ <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL t3O_ FOUNDATION� PROPERTY LINE- <br /> IX <br /> INEIX LIFT STATION SIZE_ 22)--'qALTYPE OF PUMP U;;nSAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> CLLEACHING LINE NUMBER&LENGTH OF LINES _/ INFILTRATOR CHAMBERS <br /> r / <br /> DISTANCE TO NEAREST: WELLIIp FOUNDATION S� PROPERTY LINE. <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> i <br /> j8I SEEPAGE PITS WIDTH LENGTH DEPTH 2§ <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 J <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 /> ORDIANCES, ATE LAWS,AND RU AND REGULATIONS OF SAN JOAQUIN COUNTY. / O <br /> SIGNED: TITLE:�Q%Ae!/ `-++�- DATE: <br /> Ph <br /> P <br /> I' <br /> y1 <br /> O <br /> i <br /> 8 NJ A I <br /> F VIR N FN 1 H AI T DI Sln <br /> FOR DEPARTMENT USF:ONLY <br /> APPLICATION ACCEPTED BY: DATE: O <br /> TANK,PIT,OR SU41WNSPE EI Y: DATE: <br /> FINAL INSPECTION BY: A n /1 <br /> COMMENTS: IDro` AkL VK C-06 T MPN v fill <br /> PECODE Sdj AMOUNT IIECh / RECEIVEDB DATE PERMIT/SERVICE REQUEST• SEPTIC 1De <br /> INFO REMITTED <br />