Laserfiche WebLink
_Y 1 •Tt�,,, - APPLICApON FOR LIQUID WASTE PERMIT <br /> hL T k SAN JOAQIJ COUNTY PUBLIC HEALTH SERVICES <br /> Q Gnr�y, � � ENVIRONMENTAL HEALTH DIVISION <br /> 0-10IIA " l� P.Q. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 <br /> (209) 468-3420 <br /> h <br /> MOM•REFUNDABLE PERMIT EXPIRES 1 <br /> YEAR FROM DATE ISSUE <br /> (Compbto in Triplicate) <br /> Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This application <br /> is made in compliance with San Joaquin County Development Title, Chapter 4-1110.3 and the Standards of San Joaquin county Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# <br /> II City C Lot Size <br /> Owner's Named <br /> Address -- <br /> Contractor Phone�� <br /> Address <br /> Sub Contractor• Address Lic# Phone— <br /> TYPE <br /> hone—TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION <br /> �tI U Lie# Phone <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN2 0 FEET OF BUILDING.) <br /> J I PERI;TE8Tie}I J How man <br /> Installation willLa <br /> serve: Residence Commercial Other,�jg� �UseApplientiaa/ _ <br /> Number of living unitsn Number of bedrooms <br /> Character of ooll to a depth of 3 feet; Nurmber of "Joyeag. <br /> Pit/sump Sail Character: Water Table Depth�`_ <br /> SEPTIC TANNIOREABE TRAP [] Type/Mfg <br /> Capacity No. Comportmmmenta�_ <br /> PKB TREATMENT PLANT [ ] Distance to nearest: well��� � <br /> Foundation /� Property iine �'7` <br /> LIFT STATION[7 Size Type of' Pump Sand Oil Separator (enclosed system) <br /> LEACHING LINE �� [7 No. & length of lines Distance to Nearest: well <br /> __ Foundation Property Line <br /> FILTER BED �} p Width Length Depth ++ +, <br /> well Foundation Property Line <br /> MOUNDED •� <br /> I� Q Width Length Depth ° Is Well <br /> SEEPAGE PITS 0 Depth S1Ze Foundation Property Line <br /> Humber Is Is well Foundation Pr <br /> o rtY <br /> LineSUMPS widt Length� Well Foundation '� _ <br /> Property Line <br /> DISPOSAL PONDS ;: [] Width Length Depth Is if well �? <br /> Foundation Property Line <br /> I hereby certify that I have prepared this application and that the? <br /> 11111t 1111and State Laws, and Rules and Regulations of the San Joaquin Count (i dQ� in accordance with San Joaquin County Ordinances— <br /> : "I certify that in the performance of the work for which this p rmi is�ssregr Iishatldno employ arny certifies the annex <br /> to became subject to workman's compensation laws of California.° Contractor's hiring or sub-contracting person ignatureccertifiesh a rthas <br /> e <br /> following: "I.certify that in the performance of the work for wh!AVJJi8{&rIsP9pJ issued, I shall employ persons subject to workman' <br /> compensation laws of California." <br /> The applicant must call 24 hours in advance for all required Inapeetiona, c-gtAtt Cf, Ae?}R8 below- <br /> Signedx PUBLIC Ii CAI <br /> ' Title Date: <br /> PLOT PLAN (Draw to Scale) Scale <br /> " to• <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal s stem or <br /> 2. Outline of.the property, with dimensions and North direction. Y <br /> 3. Dimensioned outlines and location of all existing and proposed 5. proposed expansion of sewage disposal systems. <br /> Location of wells within radius of 150 ft. an <br /> structures, ,,including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. T� <br /> �I <br /> I, <br /> I' <br /> w <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Ct JLuerc/'� _ Date: - , , !�� Area: <br /> Tank, Pit or Sump Inspection by DateFinal Inspection by­'Z�,, _ DateyJ <br /> Additional comnen'ts: A5 l)�U _��_ `jIlyll og fSSin1 &W,;"t �jj 5G{ �i0 � �AKLV �LLi,.� y S)±ouifti tJ4f �(� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEEINFO AMOUNT REMITTED (NEC CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE 1 <br /> r <br /> :E <br /> �i <br />� �'I <br />