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LIQUID WASTE PERMIT ��9 <br /> SAN JOAQI )UNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 1 TH DIVls 4 HR N C.•.F91 <br /> MY _. ,(EBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209, 3420 RE(DUES-77EC <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FC-3 R ^L_I <br /> _ <br /> JOB ADDRESS <br /> S <br /> CITY/ZIP ©.�/ t PARCEL SIZE/APN <br /> E ' <br /> OWNER NAME ADDRESS _ <br /> pfd <br /> CITY/ZIP —PHONE-2:2 <br /> CONTRACTOR ADDRESS­ <br /> — <br /> DDRESS <br /> CITY/ZIP ' PHONE� �� <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ N STALLATION REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ffRFSIDENCE ❑COMMERICIAL [3 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:--3- NUMBER OF EMPLOYEES <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: � Lo/l PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH a <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS--— <br /> •PKG TREATMENT PLANT DISTANCE TO NEAREST: WELL {L 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 D O FOUNDATION `� PROPERTY LINE �' Q <br /> ❑FILTER BED WIDTH LENGTH DEPTHR1 j <br /> DISTANCE TO NEAREST: WELL LI C1 <br /> . FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL —T FOUNDATION PROPERTY LINE <br /> 5 LENGTH DEPTH 2 <br /> ❑SEEPAGE PITS WIDTH f Zf 0 /�Q 0 ) <br /> DISTANCE TO NEAREST: WELL `4 6 0 FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH p <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,/AS^ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: i',L0'V IZ I� _0 TITLE: /v�A DATE: <br /> ,7 <br /> fr i <br /> c <br /> j <br /> FOR DEPA TMENT USE ONLY <br /> - FOR DEPARTMENT USE ONLY <br /> DATE: <br /> APPLICATION ACCEPTED <br /> DATE: <br /> TANK,PIT,OR SUMP INSPECTED BY: <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> -119 -00 <br /> PE CODE SC AMOUNT SCK RECEIVED BY DATE <br /> PERMIT/SERVICE REQUEST# SEPTIC ID# <br /> INFO -M TTED <br />