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y - <br /> f: <br /> I: LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> :�i ��'8 S• f11 E.WEBER AVE.,3R11FLOOR,STOCKTON,CA 95202 {209)468-3420 <br /> 'JNON-REFUNDAB,E PERMIT E IRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP <br /> I <br /> j PARCEL SIZElAPN P Q "" <br /> �I OWNER NAME ADDRESS fD ! � ^•-..�.�•- `� <br /> r CITYIZIP O <br /> Oil PHONE <br /> jE CONTRACTOR <br /> ADDRESS <br /> CITYlLIP PHONE <br /> I! GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <br /> j <br /> j PERC TEST(S) ( ) HOW MANY <br /> APPLICATION k <br /> Ei 'TYPE OF SEPTIC WORK: 2RESIDENCE <br /> STALLATION r REPAIR)ADD_ [TION <br /> -- ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: COMMERICIAL <br /> i. 13 OTHER <br /> li NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br /> ` }} NUMBER OF EMPLOYEES: <br /> it iJ CHARACTER OF SOIL TO A DEPTH OF3 FEET: <br /> 1� PIT/SUMP SOIL C AR CA TER: WATER TABLED PTH <br /> II Ei ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY <br /> NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT9 , �q <br /> f� DISTANCE TO NEAREST: WELL/ TION F NDATIOIV7 PROPERTY LINE t1 S/CJ <br /> EI E, ❑ <br /> LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> II ❑LEACHING LINE NUMBER&LENGTH OF LINES / Q <br /> ! INFILTRATOR CHAMBERS <br /> �I /�� <br /> JJ DISTANCE TO NEAREST: WELL-46- --/MNDATION PROPERTY LINE <br /> l I! ❑FILTER BED WIDTH LENGTH DEPTH <br /> r �l EI DISTANCE TO NEAREST: WELL FOUNDATION; PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH <br /> DEPTH <br /> j DISTANCE TO NEAREST: WELL FOUNDATION <br /> PROPERTY LINE <br /> f� ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> i� <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH <br /> ij LENGTH DEPTH <br /> :s <br /> f Ei DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I� ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> j <br /> " + DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,AND RU ND REGULA IONS F SAN JOAQUIN COUNTY. <br /> f+ SIGNED: <br /> TITLE: DATE: <br /> I <br /> E� a <br /> l� <br /> v <br /> k• _ <br /> I <br /> L � <br /> I 1 <br /> j CI <br /> !I <br /> !I ` <br /> ! f <br /> ij <br /> SA J AU I C;: 1 : <br /> jl F Ivin m,,r:NT L `i P,I?" �qlv iI i <br /> .�'�., ...;—FCR.D:rnsars..��T��s; or:•••r-�---.�. - �•._ ._ _ �'� <br /> f _ = <br /> 1 APPLICATION ACCEPTED BY: <br /> i ! F <br /> j 'TANK,PIT,OR SUMP INSPECTED BY: DATE11 : <br /> -FINAL INSPECTION 8DATE:Y: i <br /> COMMENTS: <br /> 4 inn <br /> i! <br /> € q PECODE. SC AMOUNT CHE RECEIVED BY PATE <br /> !I INFO REMITTED CASH PERMIT/SERVICE REQUEST N SEPTIC IDN <br /> l: <br /> s 2-9 36 a ScoZ 2� <br />