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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIOP S <br /> 304 E.WEBER AVE.-ill FLOOR.STOCKTON,CA 95202 (209)468-3420 <br /> �NON-RJE�FUND1A.BLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS `-'`� (v :'IIS 1 '-� "� (. --- -- <br /> __. <br /> CITY/ZIP 4 I 1, 1'ARCEI.SI/F/APN +03o~) �C"� <br /> ri <br /> OWNER NAMERCS- --.---- ojs�2 'y'" <br /> CITYIZIP +- L C/I PHONE (Z�y) C _ - <br /> CONTRACI'OR a✓ ADDRES _ <br /> CITY/ZIP---,,. _ _.�_�.___._........__-___ PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE-SECTION <br /> FERC TEST(S) ( ) IIOW MANY -_-___- APPLICATION M: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATIONREPAIR/ADDITION L� D (T <br /> FSTRI7ION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE OMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES <br /> C HARACPER OF SOIL TO A DEP'T'H OF 3 FEET: Pl'17SUMP SOIL CHARACI'ER: WATER TABLE DEPTH <br /> SEPTIC TAN TYPF./MFCi�(f� . CAPACITY�� ( <br /> .RF.ASF TRAP !'N MH£R OF COMPARTMENTS / <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE - <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARA'T'OR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELI. FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION _ PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTII <br /> DISTANCE TO NEAREST: WELI, FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPfH <br /> DISTANCE TO NEAREST: WELL. FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH ^ LENGTH DEPTH <br /> DISTANCETONEAREST: WELL FOUNDATION PROPERTYI.INF. <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICA'T'ION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,S ATE LA WS,ANI UL' A D �F.G.U,L,A�TIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: �_ �� 'w�sti'ZC•� TITLE:E: f�Y DATE:7y 7"C Grr <br /> I . � <br /> 10 <br /> A 1 - <br /> � r - <br /> - - _ Sti(l� ,,� , -�--- - - <br /> -.. �1. <br /> Icis <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: f �-_. _-D TE:�� <br /> TANK,PIT,OR SUMP INSPECTED BY: _ �- DATE: <br /> FINAL INSPECTION BY: _ <br /> COMMENTS: -7`2to- Q 2 <br /> F LA <br /> PE CODE SC AMOUNT 'HECK RECEIVED BY DATE PERMIT/SERVICE REQLTST M SEPTIC IDO <br /> INFO ReMITTED <br /> -711)1 <br /> (� - 3 L+ 2-3 2 4 h r 5ad, wtn,e�e� aAt* <br />