Laserfiche WebLink
APPLICATION FOR LIQUID WASTE PERMIT SCANNED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.Q. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 86201-0388 <br /> (209) 488.3420 <br /> RON:REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete 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 9-1110.3 and the Standards o San Joaquin County Public Health <br /> Services, Environmental Health Division./ <br /> Job Address/or APN# V Cit Lot Size <br /> i <br /> Owner's Name ass 0 Phone <br /> �� G n <br /> Contracto Address Lic# O Ph <br /> Sub Contractor " Address J Lic# 00-- Phone <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRIADDITION 11K DESTRUCTION I I PERC TESTIsI I I Now many <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEVER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Laa4 Use Application# <br /> Installation will serve: Residence Commercial other <br /> Number of living unite: Number of bedroomai�_ ber of emp&i—­;z2zrc)" <br /> Character of soft to a depth of 3 feet: ItAump So11 ter Tablr Depth <br /> SEPTIC TANKIOREASETRAP [] Type/Mfg apacitNo. Compartments <br /> PKG TREATMENT PLANT [ ] Distance to nearest; well Foundation Property line <br /> LIFT STATION[] a Ty of Pump Sand oil Sepa�r�atoo (enclosed syst ) <br /> LEACHING LINE l4' No. & length of lines Distance to Nearest: We11. oundation �d Property Line <br /> FILTER RED [] Width Length Depth +' " Well Foundation Property Line <br /> MOUNDED [] Width Length Depth it It Well Foundation Property Line <br /> SEEPAGE PITS [] Depth Size Number 01 Is Well Foundation Property Line <br /> 1I <br /> SUMPS 6/Width, Length Depth " It Wel�Foundation�� Property Line' <br /> DISPOSAL PONDS [] Width Length Depth " " Weii Foundation Property Line <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances <br /> and State Laws, and Rules and Regulations of the San Joaquin County, Home owner or licensed agent's signature certifies the following <br /> : "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such a mariner as <br /> to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the <br /> following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensation laws of California." <br /> The applicant must call 24 urs in adv all requires Inspections. Complete drawing below. /�, �� / may+ <br /> Signed X � TitI.e:�+-W"f Date: J —` — <br /> PLOT PLAN ( to Scale) Scale " to <br /> 1. Names of rests or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, with dimensions and Horth direction. proposed expansion of sewage disposal system. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, erpro rty or adjoining property. <br /> and walks. <br /> r <br /> Jur <br /> r <br /> t <br /> I PF <br /> ,, <br /> H-Al. i SE SIC $ <br /> +RO It A�,. 51 <br /> FF <br /> DEPARTMENT <br /> Application Accepted by w 1 Date: ea: <br /> Tank, Pit or u, Inspection by� Datezz, h—,?1fAt Inspection b Datg� A <br /> Additional Comments: / <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INFO AMOUNT REMITTED EC CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE# <br />