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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 , <br /> NON-ill?FUNDAIII,I?PI-:RMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> cov. <br /> 1013 ADDRESS lzlq <br /> g /'` <br /> CITY/ZIP [i1 Li V� 1 PPAARCCEELSIIZF/AAPN "v <br /> OWNER NAME � _ DDREES'SI�JCA90 -`"'�'� y� � <br /> CITY/ZIP /-1 /1 PHONE _1- <br /> CONTRACTOR ( I D ��Cc��� �� -�^ n• ADDRESS -)jaS H �S&n( ? <br /> /' <br /> CITY/ZIP 1 C [V PHONE �Lv <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_//RAANGE//.� SECTION <br /> 5/4 PERCTEST(S) V`HOWMANY I APPLICATION#: _✓1-6 3 <br /> TYPE OFSEPPIC WORK: ❑ NCW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑O•I'HER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG 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 /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION °ROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCETO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WID'T'H LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> �J <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH f� <br /> `'\ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE 1 <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY - <br /> ORDIANCI^STATE,LAWS,AND RULES <br /> AND <br /> �i �M�REGULATIONS OF SAN JOAQUIN <br /> COUNTY. ���y/ � \ <br /> SIGNED:- I l ll� j �� L`{'t'l I V SM l-&( _Xhc TITLE:V� DATE:l� �•O , <br /> C11 <br /> rT <br /> y <br /> 4 <br /> J <br /> i <br /> �� I <br /> N <br /> a � <br /> f17,1 <br /> t- jHl Ji AU 11fJ .;i i'iia i <br /> DP:PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: < %'�� I toL 1---DATE: <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE:_ <br /> FINALINSPEC IO BY: <br /> COMMENTS: <br /> I <br /> PECODE SC AMOUNT CHECK N! RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO R6MIT7ED <br /> 2 S2 �`IfP 1 0oc— <br />