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LIQUID WASTE PERMIT 24 F 4R <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION..-C� <br /> 304 E WEBER AVE.,3RD FLOOR.STOCKTON,CA 95202 (209)468-3-420 <br /> t-f - <br /> N UNDAB MITE%PIRECtYEAR RR ISSUED_ '-D <br /> SIS <br /> �13�6 -- T Sr'3i-�. i �t <br /> JOB ADDRF. , v <br /> CITY2IP_ PARCEL S IZEIAPN � <br /> OWNER NAMEHEALADDRESS — /DV <br /> CITYILIP {`'�L _y A f PHONE <br /> CONIRACT��O``R��`/�/eA./��//����. .�ST � JRL►.=� t lv L_ADDRFSS4 <br /> CITYILIPSTCC ��R PHONE �'�--- <br /> GEOGRAPHICALNFORMATION:COORDIANTES: X Y TOWNS HTP___RANGE_SECIION <br /> PERC TEST(S)( )HOW MANY APPLICATION e: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ,�,.��{{ <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICAL VOTHER�� Re+'r� <br /> NUMBER OF LIVING U.NITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES:— <br /> CHARACTER <br /> MPLOYEES:_CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PiTISUMP SOIL CHAARRAACC/TEER: WATER TABLE DEPTH <br /> SEPTIC TANKIOREASE TRAP TYPEIMFG CV6 CAPACITYj <br /> -_�C.25d, -NUMBEROFCOMPARTMENTS 2 <br /> 13PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL 100 FOUNDATION _ 0 PROPERTY LINE <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER A.LENGTH OF LNES ! INFILTRATOR CHAMBERS <br /> DISTANCE TON EAREST: WELL FOUNDATION W2OPERTY LI NT <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 /> 13 SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION_..____`PROPERTY LINE— <br /> E3 SUMPS <br /> INE❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST.' WELL FOUNDATION PROPERTY LINE <br /> I HERE CERTIFY THAT 1 VE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE NEIN C�C1O�R(1D1AN.�rC�E UITH SAN JOAQUIN C UNTY <br /> URD :C E L S,A19h R GULAT10N5 Of SAN JOAQUINCOUNTY. sn+,or-�_�ILi�SGi----- <br /> TITL DATE: <br /> SIGN w\ <br /> I Y <br /> ttl <br /> L <br /> --- <br /> -+- t R I r 1 I `� <br /> J <br /> ;t <br /> - <br /> -i <br /> -f # f7l (.{. <br /> RD P MENT USE ONLY Rf ^ ) <br /> AT <br /> APPLICATION ACCEPTED BY: <br /> TANK.PR.OR SUMP INS➢E <br /> � I <br /> FINAL INSPECDON BY:. <br /> COMMENTS: <br /> PECODE SC AMOUNT CHECK Of RECEIVEDBY DATE P f.F. _ SEPRC]D+' <br /> + INFO REM CASH <br /> I <br />