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LIQUID WASTE PERMIT, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIso 4. R N C)"T 9.C` -- <br /> 304 E.WEBER AVE.,3RD FLOOR,STOCKTON,CA 95202 (209)468-3420 _ _ ' <br /> NOON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FCI,r R. ^+ L-L- <br /> JOB ADDRESs7 <br /> r <br /> CITY/ZIP D2Y PARCEL SIZFIAPN <br /> f � _ <br /> OWNER NAME ADDRESS ,t <br /> CITY/ZIP <br /> PHONE /^ <br /> CONTRACTOR ADDRESS ` d9 <br /> CITY/ZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <br /> A <br /> PERC TEST(S) ( ) HOW MANY ��APPLICATION#: <br /> TYPE OF SEPTIC WORK: 13 NN STALLATION 6 REPAIWADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RC'1 ESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OFF BEDROOMS: NUMBER OF EMPLOYEES <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: `� 4/�/l PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH Q <br /> ❑SEPTIC TANK/GREASE TRAP TYPE/MFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTXNCE TO NEAREST: WELL FOUNDATION PROPERTY LINE__4I4.Do <br /> ❑LIFT STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES_ _/ o INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL D D FOUNDATION PROPERTY PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH _ <br /> DISTANCE TO NEAREST: WELL J FOUNDATION:- � PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> / DISTANCE TO NEAREST: WELL r FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL '�6 Q FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH P <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE 1 <br /> .a <br /> ❑DISPOSAL PONDS'WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> I IIEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCES,STATE LAWS,/ANND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: r7l7l ��lV �� TITLE: e�7�1 DATE: <br /> tY <br /> 17 i <br /> OF <br /> AffF <br /> .s <br /> d / <br /> FOR DEJTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE: ✓ t.A�G/ <br /> TANK.a OR SUMP INSPECTED BY: _DATE:_, <br /> FINAL INSPECTION BY: <br /> COMMENTS: L _U t 4A cn2 <br /> PE CODESC AMOUNT <br /> QEK#/ RECGIVEDBY DATE PERMIT/SERVICE REQUEST# SEPTIC[DO <br /> INFO REMITTED CASH <br /> .a <br />