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LIQUID WASTE PERM. <br /> k `L',"• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ _ <br /> 304 E.W EBER AVE.,3ND FLOOR,STOCKTON,CA 95202 (209)468-342024 H <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IR F C')U E S r� <br /> JOB ADDRESS I N S Fj"E <br /> CITY/ZIP_ PARCEL SI^Z�E/�APN <br /> OWNER NAME f✓ ./ IADDRESS <br /> PHONE/ <br /> CITY/ZIP �y �y <br /> ADDRESS ' <br /> / '3 <br /> CONTRACTOR �' ' <br /> ' PHONE (. I <br /> CITY/ZIPS // <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y <br /> TOW NSHIP_RANGE_SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION <br /> REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: FSIDENCE <br /> ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UN[TS: <br /> NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_____ <br /> �'�;1 �/ PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG <br /> 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 CHAMBER) <br /> /l V <br /> E PROPERTY LINE <br /> DISTANCE TO NEAREST: WELL�-FOUNDATION — <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 /> )SEEPAGE PITS WIDTH LENGTH <br /> DISTANCE TO NEAREST:DEPTH WELL <br /> // / TFOUNDATION 6 PROPERTY LINEJ1 f`� <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION <br /> PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PR ARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES, F� AND R ESA D REGULATIONS OF JOAQUIN COUNTY. <br /> TITLE: 6- ' DATE: <br /> SIGNED: <br /> FOR DEPARTMENT USE ONLY <br /> rr� DATE: (J <br /> APPLICATION ACCEPTED BY:1—L -. •��- -— <br /> DATE:_ <br /> TANK.PIT,OR SUMP INSPECTED BY: <br /> FINAL INSPECTION BY: <br /> COMMENTS: y/ - <br /> PE CODE' SC AMOUNT CKAe RECEIVED BY DATE PERMIT/SERVICEREQI TM <br /> SEPTIC IDM <br /> INFO -M ED n ^ <br />