FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

! `APPLICATION FOR LIQUID WASTE PERMIT e ~' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNiSION 304 EAST WEBER AVENUE, STOCKTON,CA 95202 j (209)468-3420 f NOW-REFUNDABLE PERMIT EXP18E8 IYEAR MOM BALE MED IClmpletn in TripBatd I[ APPLICATION 19 HERESY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK 1JESC WEED. 77AS APPLICATION L MAGE JH COMPLIANCE WITH SAH 'JOAORAN COUNTY DEVELOI#IENV TTN.E,CHAPT}ER 8-11/10.3 AND THE OF SAN JOAOUIR COUNTY FUSLIC IIEl1LTH SERVICES.EMVIHDNMEH�TA1L HEALTH DIVISION. I JOS ADORESUOR APNI I.,L J !D • �� "^ City} � f��G L��1 `� �LOTT,E,IZE fI ,� - - •F+;�lJ . j 7 - IG 'i G�7 PHONE `«[& 5G 0 ADDRESS ! ;I tICNI R'HONE_ t ADD1EeB MI6 CONTRACTOR LRCS Ih TYPE OF SEPTIO MIG11K: NEIN DISTALIAITION 0 IIEPAmAODIiION ❑ ...On. TIO z PO IC SEPTSYSTEM pERYM1TTED E pUXX SEWER IB AVAILABLE WTTMN 200 FEET OF Mtn DING 1 I! Film TESihI l 1 NOW MARY i a I I Apdootan MISTALLATION WILL SOME:- RESIDENCE E3 COMMERCIAL❑ OTHER ❑ IREIMEL OF LIVING URNTS: NUMBER OF SEOROOMS: NUNMM OF EMPLOY I} CHARACTER OF SOIL TO A DEPTH OF!FEET: Pr/SUMP SOIL CHARACTER: WATER TAKE- SORA TARK"MASE TRAP ❑TYPEIMFG CAPACITY 1} NOT.COMPARTMENTS FKe TREATMENT KART❑ DISTANCE TO NEAREST: WELL FOUNDATION. I PROPt*ITY tm �t LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR!ENCLOSED SVSTEM E LEACHING LINE [3 No.S LEFI0TIN OF LINES TO NEAREST:WELL PROPERTY LINE FDUNDATmN 'h PLTE R EEO ❑WIDTH NG LETH DEPTH RE DISTANCE TO NEAREST:WELL FOUNDATtDH PROPERTY LINE N1101ENO/a ❑WIDTH L,EFNGTH DEPTH DISTANCE TO NEAREST:WELL I IiFOUNDATION PROPERTY LINE, - SWAOE PTS O SIZ DEP- E NUMBER DISTANCE TO NEAREST:WELL 7{ FOIlNdATIDN PROPERTY LINE 'h LENGTH DEPTH DISTANCE TO NEAREST:WELL II FOUNDATION PROPERIY UNE am", O WIDTH DISPOSAL PORaa 0 WIDTH LENGTH DEPTH DISTANCE TO NEATEST:WELL " FOINNDATWN PROPERTY LIINE !� it I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAH JOAOIIIN COUNTY ORDINANCES AHD STATE LAWS,AND RULES N AND REOVLATIONS OF THE SAN JOAOUCOUNTY.HOME OWNER OR LNCENSED AGENT'S SIGNATURE CERTIF MS THE FOLIIJWIlG:M CERTIFY THAT N THE Pu"FMAMCE OF THE wow FOR WHICH TMS PEIMOr a tSSUE D,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO VVOMMAMS COMPENSATION LAWS OF CALWOMA.- CONTRACTOR'S NNNWINO OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:h CERTIFY THAT IN THE RMANCE OF THE WORK FOR WHICH THIS PERMIT M ISSUED,I SHALL EMPLOY PERSONS SUSPECT TO VYORKMAM S COMPQlSATION 1 AYMS OF CALIFORNIA.- THE APFLOAMT MUST C HO,St/W ADVANCE FOR ALL REQUIRED IISFEC110RS. C06RLETE DRAWIIO BELOW. { �.�! .h ^G �1 1 r, G , "1! Trn DATE PLOT PLAN!DRAW TO SCALES SCALE_ - 'se 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY' •. LOCATION DF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Z. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. i. LOCATION OF WELLS VIRTFNIN RADIUS OF ONE 1AlINOfEO FIFTY RR.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOIBNG PROPERTY. .... ............... .. ;..., .,.,....-..-. .............E.............L.....<-......:......:..... .. .. ..:.............:.. it .....?.............E......,.....`....... .. ., .. ... - ........ .. �k ... .. .............:.....................-. .. .. I! :.......>......... :.. .. .. r . ......i..................`.............-......E. ;. .. .... .. ..:.. : I f : .....,......p............................................. ..;....,..:...-..,......: .,:...... .-.. ...... , �. .. 3AN 1:J+� IT I"GZP/ARTM(�j�T I[ME ONLY APPLICATION ACCEPTED SY v' DATE: I 111A: TANK.Pr OR SUMP INSPECTIOIN BY DATE ! ! FINAL INSPECTIONISM DATE �j ADD! KN&C.OMMEMTB: ACCOUNTING ONLY: AID/ - PACO - v M CODE FEE INFO AMOUNT IUMITED CHECKSICASH RECEIVED BY DATE SR!PERMIT RIAIoodI INVOICE S Pub.HeeMh Sen.-ErrAro.174(3196)