Laserfiche WebLink
APPLICATION FOR LIQUID WASTE PERMITS Cn1 \ <br /> E SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL 14EALTH DIVISION <br /> 304 EAST WEBER 2VVE}N �S2OCKTON,CA 95202 OEC 3 j 199$ <br /> N9N•REFUN�A9LE PfRFdI>•EXPIRES I YfAR FR91N GATE 1SSUEi'1 'uu�� .�„ir�v;., <br /> 5 IClmPMTf FR Trplief E.l `:IVViROtuhm ATL FIF�-gL'r�I�.�aI�t��C,,11EIIS <br /> 3 APPLICATION N HEREBY MAGE TO THE BAN JOAgUIH CO Way FOR A PERMIT TO CONSTRUCT ANE)Mn INSTALL THE WORK DESCRIBED.THIS APpUCATON IS MAD <br /> IN Gdl'SPI] <br /> f <br /> JOAQUIN COUNTY DEVELOPMENT <br /> TITLE.CHAFFER 9-1110.3 AND INF 6TANOA WRH BAN <br /> Z O A ¢ L r � OU N CO.UNi�[I`UCC�HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRfseIOR�AP�N/�_I 1/1y1 l/1.'JL` j37 <br /> L �L. <br /> OWNER'S NAME`J G k' �, +- n�+'I�jOT�j81ZF./y'7'C/�r'� <br /> AbbRE89 S ((++ rf PHONE CJ a f r C��3 7 <br /> CONTRAC'RORJl 1 IZl CClZuac�t'L� L' <br /> AOOP:E66 _-3 <br /> LJCI PHONE Y <br /> SVB CONTRACTOR ADDRESS <br /> lk r <br /> Ucs PHONE <br /> TYPE OF PEPTIC WORK: NEW INSTALLATION Q REPMUAOOITIa <br /> DESTRUCTION❑ <br /> IKP <br /> ONO SEPTIC SYSTEM PERMITTEO IF PUBLIC SEWER 16 AVAILABLE WITHIN 2130 FEET OF BUILDING.[ <br /> PSIC TESTIH[I NOW MARY <br /> INSTALLATION NULL NONE: RESIDENCEApOmtl^f <br /> COMMERCIAL Q OTHER❑ <br /> "UMSEA OF LMNG UIBT6: IILSAB91 OF■FVROOMS- <br /> / HUMSIR OF EMPLOYEES: /' <br /> CHARACTER OF EOR TO A D[PIR{OF 9— k C'! PIT/SUMp SOIL CHARACTER: �'/JR4 WATER TABLE DEPTH � <br /> F <br /> LEPITO TANIVOREASE TARP QTVPFJMFG CAPACITY <br /> NO,COMPAATMENFS <br /> PKO TAF4TMEIY PLANT❑ DISTANCE TO NEAREST: WELL I <br /> rI----�, FOUNDATION PROPERTY UNE <br /> LIFT N7ATION LJ SIZE TYPE OF PUMP- �SAND OIL SEPARATOR IENCLOSED RYSTEMI <br /> LEACHING UNE NO.i LENGTH OF MINTSFILTM <br /> /t - � <br /> L..Z—. .,ST...TO MEANEST: E PO IP FO.N.TON 7-20 PROPERTY— 21- +f . <br /> MOUNDED <br /> 17 W10TH LENGTH W <br /> DEPFH DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPEIrTY LINE <br /> MOLATDD ❑WIDTH LENGTH DEFTH DISTANCE TO NEAREST:WELL <br /> fEFPAOE PIT@ �� N - PoUNDATWN PROPERTY LINE <br /> �""� NUMBER DISTANCE TO NEAREST! D�� FOUNDATION <br /> Q WIDTH 7 PROPERTY LINE <br /> eWNPB LENGTH OEITN DIBTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS Q WIDTH LENGTH--DEPTH D48TANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT HAVE THIS APpLRCA NAND THAT THE WOR(WILL RE PONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWe,AND glR.E9 <br /> AND REO Ff8 BAR ADUIN MY.HOME ER ORLICEN8ED AGENT'8&ONATURE CERTIFIES THE FOLLOMNO:'I LEWfFYTHAT INTHEPERPORMANCE OF THEWOFK FOR YVISCH <br /> 1 THIS IT M '1 F NOT EM ANY PERBO SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAJIFOFPRA.' CoHFRACTO, 111RNB OR <br /> `{ SU-CONTRACTI BKINA RE CERFI B TH FOILOWI ..CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> RKMAN'B COM T N RMA.' F C#MUST ALL M MOURN IN ADVANCE FOR ALL RWCMREO d/PECTIONB.COMPLETEOAAWINO BELOW. <br /> LI GNED X TITLE: 1 DATE! l <br /> I{iL' I <br /> PLOT PLAN IPMW 7O SCALE SCALE__.to <br /> 1.NAMES OF STREETS OR ROAD REST TO OR BOUNDING THE PROPERTY, .k <br /> 2.OUTLJNE OF THE PROPERTY.WfTN dMM81ON8 ANO NORTH Of1ECTgN, A.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 111���... 3,PIMEHBOHEp OUILMEB ANO LOCATION OF AIL EXIEXPANS <br /> STING ANO PROPOSED STRUCTURES, <br /> ION or sEWAOF DISPOSAL <br /> INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS. HUNDRED FIFTY FT.ON <br /> S. <br /> LOCATION OF WELLS WITMH gAgUB p ENE <br /> _ THE R10i�RTy OR AOJDINRIG RgPERFY. <br /> ............ <br /> . ......... <br /> Vl .......... <br /> ............. <br /> }�-. ..... . o <br /> f <br /> T... <br /> 4 <br /> r <br /> /], <br /> 1 ” <br /> I <br /> ry <br /> Iv .. <br /> 199, <br /> k �C u"� avaa Fi�N ser�y r <br /> ..... <br /> ��LTF1'cWS4,.. { <br /> . _ - _. o- .. <br /> ;.... <br /> R .. <br /> r `n <br /> a. .. ...w.. �J <br /> t .. <br /> .. .. <br /> ..... <br /> I <br /> RPEPAFTM USE ONLY <br /> APPLICATION ACCEPTED BY T.'�+/+ VL L GATE L- <br /> AREA: <br /> R TAJB(, OR BUMP SISPECTOI!BY -f <br /> 1 DATE /�' - FIN/y,INSPECTION BY / DATE <br /># <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID# FACS , <br /> P£CODE FEE INF AMOUNT ADAI ILEO CHECK! ASH RECEIVED NY PATE 6q lPHNTI7 NLMSITI <br /> IHVOfCE <br /> Pub.Heath Sam-ERviro.174(3195 <br /> A <br />