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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUPLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE 3"'FLOOR,STOCKTON,CA 95202(2.09)468-3420 <br /> NON-REFUND/}AB`LE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESSQ /l,/ � 1�,A APN �) ) .� <br /> 1 <br /> PARCEL SIZE: <br /> C1TYIZIP_ _/�N . � 1 BUILDING PERMIT A <br /> OWNER NAME <br /> CITY/ZIP �'+1�� r[�� J,] PHONE NUMBER <br /> CONTRACTOR -_ ADFRE55 <br /> CITYIZIP PHONE NUMBER <br /> GEOGRAPHICAL INFORMATION: COORDINATES: X _. - Y - _ TOWNSHIP RANGE_ SECTION <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE; NUMBER OF LIVING UNITS_ <br /> ❑ NEW INSTALLATION ❑ RESIDENCE NUMBER OFBF.DFtOOMS: <br /> ❑ REPAIR/ADDITION ❑ COMMERCIAL <br /> i DESTRUCTION ❑ OTIIER NUMBER OF EMPLOYEES; <br /> ❑ ENGINEERED,ALTERNATIVE <br /> CHARACTER OF SOIL TO DEPTH OF 3': PITISUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> ❑ PERC TEST(S) HOW MANY APPLICATION p <br /> ❑ SEPTIC TANK TYPErMFG CAPACITY 4 OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY #OFCOMPARTMENTS ` <br /> ❑ PKGTX PLANT DISTANCE TO NEAREST: WELL FOLNDATION � PROPERTY LINE— �^ <br /> ❑ LI FT STATION SIZE TYPE OF PUMP <br /> SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINE OF LINES: LFNGTII OF LINES: DISTANCK TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> INFLITRATOR CHAMBERS: <br /> ❑ FILTER BED WrDTH LENGTH DEPTH_ DISTANCETONEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ MOUNDED WIDTH LENGTH DEPTH` DISTANCE TO NEAREST: WELL_ FOUNDATION PROPFRTYLINE <br /> ❑ Sumps WIDTH LENGTH DEPTIFI DISTANCKTONEAREST: WELL FOUNDATION PROPERTY LING ' <br /> ❑ - DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ SEEPAGE PITS # DIAME"IER� _ DEPTH DISTANCE TO NEAREST: WFLL FOUNDATION PROPERTYLINE <br /> I HEREBY CERTIFY THAT 1 HAV E PREPARED THIS APPLICATION AND THE WORK WILL.BE DONE IN ACCORDANCE WITII SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS <br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MUM 24 VANCE NOTICE REQUIRED FOR CNSPECTIONS—PLEASE CALL(209)468-3423 <br /> SIGNED: TITLE: <br /> . DATE; <br /> !1� <br /> � YfIN ' i } I <br /> SAN JC ;cTs�r�c1�N <br /> pf]6Li�`HEAk)I#S�itlrlCF F r <br /> .-�'NNata�11 ray rt�ni, l( lli�ln <br /> f <br /> DEPARTMENT U E ON Y77__ <br /> APPLICATION ACCEPTEF Y: - ��- DATE, Z Q?6EA EMPLOYEE[DP ��i DISTRICT _LOCATION �[ <br /> INSPECTED BY!"r` }(✓ DATE:��� Q� PERMIT HNALjo/'YES DATE: zoo /7I LN5PECTOR:��� <br /> CDMMENTS: /' <br /> 51}_ <br /> _ <br /> PE CCOE Sc INFO AMOUNT EHEC CASH RECEIVED DATE PERM I r6ERVICF REQVFSTO INVOICEM SEPTIC ID# <br /> REMITTED BY - <br /> rG� <br /> REvrseo Ia-Is-ol <br />