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IQUID WASTE PERMIT /a _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIQON <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YI,Aft FROM DATE ISSUED FIC. r' /'•• ._ <br /> � Ns <br /> JOB ADDRESS JUy✓G .SO AL S Ab fj � 'JA- /v� <br /> CITY/ZIP A 4-A fiSO <br /> PARCEL SSIIZE/APNT.2 AA G 0_12 7-j3 212 1-0 <br /> OWNER NAME _ C L/�jZM J (V U ADDRESS 10'30;2 J0;2 7_A 1_4A6e <br /> CITY/ZIP A 604-m /� �J� PHONE ,f <br /> CONTRACTOR �1t�V 1U4 �F�f'A943 r ADDRESS F Q BO Y, <br /> CITYlZIP "r/LLQr�k CA - PHONE 0 <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIPRANGE_SECTION <br /> PERCTEST(S) ( ) HOW MANY APPLICATION k: G �� <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <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 CHAMBE <br /> DISTANCE TO NEAREST: WELL FOUNDATION °Ro <br /> py <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 WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH O <br /> DIST CE TO NEAREST: WELL FOUNDATION PROPERTY LINE (, <br /> I HEREBY CERTIFI'bA '' <br /> IAVE PR: ARF APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OG <br /> ORDIANCES,STA ' ,AND RU ULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: , TITLE: / D <br /> �Z' N ATE: <br /> i <br /> FA <br /> y` <br /> R <br /> C <br /> Y <br /> J <br /> g�\ N PlS <br /> NV\ <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> TANK,PIT,OR SUMP INSPECTED BY: DATE:- <br /> FINAL INSPECTION BY: A <br /> COMMENTS: `�v v <br /> PE CODE SC AMOUNT CHECK#1 RECEIVED BY DATE PERMIVSERVICE REQUEST M SEPTIC IDM <br /> INFO REMITTED <br />