Laserfiche WebLink
LIQUID WASTE PERMIT .� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3ND FLOOR,STOCKTON,CA 95202 (209)468-3420 h' <br /> NON-REFUNDABLE,PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED <br /> JOB ADDRESS I Nq Z N S leu 99 6-4 S� 2dr? ! QfAC,E ,2P. / <br /> CITY/ZIP ��_� �^�t' /J j�r�✓�!� PARCEL SIZF/APN 10 -A C i � d 51 ��b 0 0 <br /> OWNER NAME a ,J DN (��C "V r / ADDRESS P-0- �� l0 <br /> CITY/ZIP�AJ� j) a)P-f �G�n" � 25- ( W- J PHONE G> / -/-V�55 ) _- <br /> CONTRACTOR/V\ � /- G)• //�/ ��J,I�^� 41 34l" / 10C• ADDRE///SS��S /hU— <br /> CITY/ZIP �N�J 7��/v PHONE �Z 0 / <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP RANGE SECTION <br /> PERC TEST(S) ( ) HOW MANYAPPLICATION#: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL 461 OTHER 5e--jj�L <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 TYPEIMFG 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 CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTYµ( <br /> ❑FILTER BED WIDTH LENGTH DEPTH RECEIVED <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH MAR 12 2001 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPSgTSAY LINE <br /> N JOA UI�TY �. <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH PUBLIC HEALTI I SERVICES <br /> ENVIRONMFNTAI HIM IH DIVISION <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 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCEMTATE LAWS,A -'S'ANND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: ` ��/�/yJ7^ TITLE:— fiA�� �G t� DATE: <br /> At <br /> f <br /> rq <br /> 2 O <br /> it <br /> 1+ <br /> FOR DEPARTMENT USE ONLY q - <br /> APPLICATION ACCEPTED BY: DATE: r v <br /> TANK,PIT,OR SUMP INSPECTED BY: _ ��•� �/ <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PECODE SC AMOUNT CHECK#/ RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC IDN <br /> INFO RFMITTP CASH} <br /> V <br />