Laserfiche WebLink
LIQUID WASTE PERMIT ..i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,3"'FLOOR,STOCKTON,CA 95202 (209)468-3420 <br /> NON-ItFFUNDA BLE,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �/9 Z N S TS �u � 99 ��4 Sr �2�, 066- eP. _ q <br /> CITY/ZIP IV ID (A PARCEL SIZE/APN /U _A C T -/(I <br /> OWNER NAME <br /> �2 lQ3 N _65� ADDRESS P•0- 60)( I(Y <br /> CITY/ZIP W<2:D4 6P_ Q66 r76 125_9/Q /6TV? /J PHONE � 6/7 <br /> CONTRACTOR/Y`Z G)- L�-��v/YV -1 / ZdQ ADDRESS <br /> j,,� <br /> CITY/ZIPt/ / ��/ /�/ PHONE��) <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <br /> PERC TEST(S) ( ) HOW MANY APPLICATION#: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONS` <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL 146 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 CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY <br /> ❑FILTER BED WIDTH LENGTH DEPTH RECEIVED <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH LIAR 12 2009 <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPEgg YLINE <br /> S�N JOA UIQ N c0UNTy \. <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH PUBLIC HEALTH SERVICESENVIRONMFNTAI HEAl1H 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 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIANCE TATE LAWS,AN sS ANN REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: ( �A�` TITLE:,] /G`—t� DATE: <br /> f <br /> 7-1 <br /> I At <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: v -DATE: v <br /> TANK,PIT.OR SUMP INSPECTED BY: <br /> FINAL INSPECTION BY: <br /> J �) <br /> COMMENTS: -- <br /> PE CODE SC AMOUNT CHECK#/ RECEIVED BY DATE PERMIT/SERVICE REQUEST# SEPTIC IDM <br /> INFO R!!N H-TPW CASH <br />