SU0000126 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (d a (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IB MERRY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, T1418 APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPI in 9-11 10.3 AND THE STANOARD8 OF BAN JOAQUUIIN/COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOn ADDRESSOR APIF 16 7-5-1 �//,,F�Nm//��/ /l C�� [! � CITY`S � L7 � LOT SIZE � OWNER'S NAME �" v V `7 `CADDRESS 7/(�� I `7 /J•%/-�{� ,} _PHONE 22 CONTRACTOR - i ,.A�DRES6_ L.!�. G��k LC? C, PTONE _J J�3 SUR CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRJADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PE RC TESTI.)1^^1I HOW MANY,( Applf-d..J INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS: NLWBFR OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PrT/SUMP SOIL CHARACTER: WATER TABLE DEPTH 9WIFIC TANK/ORFASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHINO LINE ❑ NO.•LENGTH OF LINER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERfTY UNE_ SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH RAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SANJOAQUIN COUNTY.(TOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIED THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHH'If T1418 PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENBATION LAW$OF CALIFORNIA.' CONTRACTOn•S HIRUNO On SUB-CONTRACTING SIGNATURE CERTIFIED THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOWMAN'B COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR/ALLLL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. �}t SIGNED% '�"�� O , TITLE: L F_e"17 f GATE: // C.) I OF PUN(DRAW TO SCALEI SCALE_ 'to 1. NAMED OF STREETS On ROADS WARES r TO OR S NDINO THE PROPERTY. e, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS NO NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINED AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WTTHIN RAdUB OF ONE HUNDRED FIT'FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS. THE PROPERTY OR ADJOINING PROPERTY. . _ I _ ....... .. � v r .. 1. .-.. .. l`rvr .. .. � . ............ ...........:......... �� ..... ......` DSC .... T ....... _ C. wax . W �� y 1998 .. _ v •>.� 1NyIRC!rVMEHTnI Hql fivIC .. ... .. ......`.. .... -�. �rH rnCS . USE ONLY I APT.ICANON ACCEPTED BY / IL�/ IC� ` DATE: I�`� f AREA: TANK,PP On SUMP INSPECTION BY �C C DATE ((/ / FINAL INSPECTION BY e�DATE ADDITIONAL COMMENTS: ACCOUNTINO ONLY: AID/ FACS (ic• / �" `' /�> c- �/ f LL - r PE CODE] FEE INTO AMOUNT RMBITED 611ECKf1CASH RECEIVED BY DATE SR/PMAfT NUMBER INVOICE/ tr � _ �� Pub.Health Serv.-Envlro.174(3/96) �y//