SR0080237 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMITtf — trC J SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOOMN,CA 95201388 (209)488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cf"lth 10 TT+Rpb) APPLICATION 18 HEREBY MADE TO THE SAN JOAOUM COUNTY FOR A PERMIT TO CONSTRUCT ANDDR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMEM�M/LE.CHAPTER 9-1110..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESWOR AAPPNN! ZS (� / /-I(�-�iV«_ /J CITY �f.•-(c/1^ LOT INZE p OWNER'S NAME 7�/At�,G(.�JC �[��J/'J ADDRESS ,%./ �/-GV��,�y�/ // rPHONE / ?3f-7Wy CONTRACTOR J(//(JZ 7D�\ S'�/J�S� ADORES#IZ� F C.hzll-GN•� J- ' � LIC, 7 ZZ) PHONE L03- -3'+ 1 OUR CONTRACTOR ADOREBS LIC# PHONE TYPE OF SEPTIC WORK: NEW MISTALLATFON REPANVADDITION❑ DESTRUCTION❑ ANO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) PEW TUTNI 1 1 HOW MANY APPRoolbn INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL❑ OTHER❑ NUMBER OF)MNG UNITB: NUMBER OF��R�ED/ROOMS:_R NUM110 OF EMPLOYERS: 2" 7OFBOR TO A DEPTH OF J FEET: G((�yR�'(f� PITMUMP SOK CHARACTER:lax WATER TABLE DEPTHK/OIFASE TRAP ❑TVPEAAFO(80KC4 0)c- --e- CAPACITY ' NO.COMPARTMENTS TREATMENT►ANT❑ DISTANCE TO NILMOT: WELLFOUNDATION 10 PROPERTY LINE�� UFT STATION 11 WE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) CC ^ LEACHING UNE NO.•LENGTH OF UNE. !,/O DISTANCE TO NEA wn WELL/00/ FOUNDATION!O I PROPERTY LINE FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE A MOUNDED ❑WIDTH LENGTH DEPT/ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE J SEEPAGE RTS DEPTH SQES<11 NUM8ER_-�4 DISTANCE TO NEMER:WFLLZ_S2L FOUNDATION / PROPERTY UNE_ SUMP ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LME DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTtFV THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND STATE AWS,AND RULES AND REGULATION8 OF THE SAN JOAOVM COUNTY.HOME OWNERO LICENSED AGENT'S BIONATURE CERTIFIES THE FOLLOWING:')CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PRM 1 SHALL NOT V ANY PERSON IN S MANNER A8 TO BECOME SUSJECT TO WORKMAN'S COMPENSATION AWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-COM CTING S CE T FOLLOWING:'I CE THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERAST IS IBSIIED,I SHALL EMPLOY PERSONS BURACT TO WOIKM "e COMPENa N AL1 RMA.' 24 HOW M ADVANCE FOR ALL RIMMED INSPECTIONS. COMPLETE DRRAWMG BELOW.. ,f SIGNED ~' TITLE: 041 1]Y-/G� DATE: PLOT PLAN IDRAW TO SCALE)SCALE 'to 1.NAMES OF 8TREETS OR ROADS NeXFWBT TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENI ONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM$. 3. DIMENSIONED OUTLINE.AND LOCATION OF ALL EXISTING AND PROPOSED I TNUCTUR E6, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON IWLUDINO COVERED MEAS SUCH A$PATIOS,DRIVEWAYS,AND WARS. THE PROPERTY OR ADJOINING PROPERTY, v� ... .. At ......�.. .......... ......-... 1_ ...:... / .. .. .. ... . : ...:.. :..... .. : - d �..�... .. 196.. .: ANJLi;Uufl iZ. '3GE3CTC'HEAL'Tf4.a R�iCF o FOR DEPARTMENT USE ONLY /� ] APPLICATION ACCEPTED BY ]Y DATE: 1 R/ AREA: �4I 19 TAM(,PIT OR BUMP INSPECTIO V DATE / I FINAL INSPECTION BY DATE I I I�l I ADDITIONAL COMMENTS: VA A-l, O t ACCOUNTING ONLY: MDI FACI PE CODE FEE INFO AMOUNT REMITTm HEC /CASH RECEIVED BY DATE M I T NUMBER INVOICE, �$0. /0 p331(