Laserfiche WebLink
C-00 r <br /> LIQUID WASTE PERMI' _ <br /> SAN J�IN COUNTY PUBLIC HEALTH SERVICES I-"NVIRONMI?N-h -.-,I;ALTH DIVISION` ►� (� ;', ' <br /> O4 E.WEBER AVE.,3ND FLOOR,STOCKTON,CA 95202 (209)468-3420 ` <br /> �] N-REFUNDABLE,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E <br /> -J� l �7 - <br /> JOB ADDRESS !^ L 5 Y (� Z�- `,I'•-- <br /> CITY/LIP 6 co W`\Q ( 11.^ PARCEL SIZE/APN DO� I U `r �/`/ 1,1�_o <br /> OWNER NAME OV 1.1��1 ADDRESS R�7 N YU?_4 DT�n LI <br /> CITY/ZIP A rto— wPHONE aoqU c.J(1 <br /> CONTRACTOR /C rr` (l ADDRESS � C V <br /> Lb <br /> /� <br /> CITY/ZIP W li` IN <br /> PHONE( 490q ) 36 7-37a L _ <br /> GEOGRAPHICAL INFORMATION: COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <br /> PERC TEST(S)Df.). / <br /> ,HOW MANY 1 APPLICATION M: <br /> TYPE OF SEPTIC WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLA'T'ION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTIIER <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 LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH PAYNIF-., <br /> fRFCF?\il__,- <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> .,f(,•CiUNT`r <br /> ❑SUMPS WIDTH LENGTH DEPTH F'UCLIC F1CAI-I'I q_f',vjcp_ `\ ^ <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTIj LII <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH \ <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE \\ <br /> I HEREBY CER IFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN T EL ',AND ULES ANDJREGULA IONS OF SAN JOAQUIN COUNTY. �}�j `' (l, <br /> SIGNED: —G.- 1 0 K{/ TITLE:���`�6 C�^S 7 DATE: 10'3L ! v <br /> cw)�� (,c Ac— <br /> I �rx•oas-lay <br /> it <br /> !r <br /> I XkPOO ii R. \ <br /> 1� <br /> I I 1 I = <br /> UR EPARTM N U'B NLY / <br /> APPLICATION ACCEPTED BY: I DATE: 1 <br /> TANK,PIT,OR SUMP INSPECTED BY. DATE._ <br /> FINAL INSPECTION BY, - <br /> COM ENTS: <br /> i <br /> PE CODE SC AMOUNT RECEIVED BY DATE PERMIT/SERVICE REQUEST 8 SEPTIC IDM <br /> INFO RdMI ASH <br />