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SQUID WASTE PERMIT C, F i'-� <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIVtF—C�U E TE ID <br /> 304 E.WEBIERAVE.,3"b FLOOR,STOCKTON,CA 95202 (209)468-3420SEPT <br /> 1 NON-REFUNDABLE PERMIT FXPIRES I YEAR FROM DLI Ir ISSUED ��S���W��y(D' N S <br /> JOB ADDRESS <br /> CITY/ZIP 4'T� PARCEL S[`LflAPN <br /> / .,OWNER NAME nL ADDRESS - <br /> j(f C1TYrL1P " a 1`"?"1 PHONE <br /> CON7'RAC7'OR ` ADDRESS x <br /> CITYIZU �7/v PHONE J�� , y <br /> GEOGRAPH[CALINFORMATION: COORDIANTES: X Y TOWNSIiII'_RANGIi_SECTION <br /> PERC TEST(S) ( ) NOW MANY APPLICATION#; <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION' ❑ DPSTRUCTIONITt� "r <br /> kol <br /> INSTALLATION WILL SERV E: 11 RESIDENCE ❑COMMERICIAL 111.1' <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS; NUMBER OF EMIT. YL"IS <br /> 117"3 <br /> CHARACTER OF SOIL TO A DFJ'TH OF 3 FEET: PIT/SUMP SOIL CHARACTER:_ WATERT ABLE DET''TH <br /> ❑SEPTICTANK/GREASETRAP TYPFIMFG_ CAPACITY NUMBER OF COMPARTMENTS_ <br /> ❑PKG TREATMENT PLANT DISTANCE-TO NEAREST: WELL FOUNDATION-- PROPFRT'Y LINE _ <br /> DLIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> j ❑LEACHING LINE NUMBER&LENGTH OFLINES ! INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION�.k_- °ROPL•:RTY LINE <br /> ❑FILTER BED WIDTH LENGTH ` DEPTH <br /> r <br /> DISTANCE TO NEAREST: WELL FDUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH . DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION I'ROPI-.RTY LINE - <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST; WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE T'ONEAREST: WELL _ FOUNDATION PROPERTY LINE <br /> I IIFRFl;1NRT1FY THAT I HAVE PREPARED THIS APPLICATION AND THE V'ORKAVILL BE DONE IN ACCORDANCE WITII SAN JoAQl11N COUNTY <br /> ORDIANC , 'TATE LAAS,AND RULES AND REGULA'T'IONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: TITLE: DATE: <br /> �I <br /> 1 <br /> N <br /> 0 <br /> ONLY <br /> APPLICATION ACCEPTED BY: < DATE -7/6 .. <br /> f' <br /> -1 0/ <br /> TANK,PIT,OR SUMP INSPE-CTF,P BY: 1 _ ATE:_ Ll __2�S. <br /> FINAL INSPECTION BY: - -' <br /> COMMENTS: <br /> f —> '� <br /> j o G b <br /> PE CODE 5C AMOUNT f CHECK#! RECEIVED BY DATE PERMPI7SERVICIi RFQUFST# SE1117CID# <br /> 1NFQ 9pmITTFQ <br />