SU0005991 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERM] 'SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVIL;,S ENVIRONMENTAL HEALTH DIVISION P,O. BOX 3K 304"EAST WEBER AVENUE, STOCK)'N, CA SWI'M :. (299) 489-3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FRO-1 DATE ISSUED (Complete in-Triplicate) APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK.DESCPJSED. THIS APPLICATION IS MADE-!N' jANCE'WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDAESSIOR APN# Q'3 n CITY LOT/SIZ -SY OWNER'S NAME Lt 11J �1 ADDRESS # PHONE 5 L r / �p�Jo < `-t'" l CONTRACTOR n ADDRESS ' LICX PHONE SUS CONTRACTOR ADDRESS_ L!C# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI10 I I HOW MANY APpRontlon Ar INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER © J NUMBER OF LIVING UNITS:_L NUMBER OF BEOROOMs: NUMBER OF EMPLOYEE'S: / G CHARACTER OF SOIL TO A DEPTH OF 3 FFET: t PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/ORFJ46E TRAP ©TYPEIMFO CAPACITY y NO.COMPARTMENTS Z, PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPEM LINE LIFT STATION© SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEMI LEACISNO UNE -9 NO.A LENGTH OF LINES DISTANCE TO NEAREST;WELLS o[} FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION - - PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 SEEPAGE PITA ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST;WELL FOt1NDATION PROPERTY LINE �7 SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION:_.,-_ PROPERTY LINE i DISPOSAL'PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL - FOUNDATION PROPERTY LINE a I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES, AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERfIFYTHAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOK41A.-`CONTRACTOR'S HIRING DR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION-1,�WB-OF„ ALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. / r SIGNED X /44 - TITLE;__.L/ G�/I ._ DATE: PLOT PLAN MRAW TO SCALE]SCALE 'to f. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL�SYSTEM.OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. - 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED'FIFTY:FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAL(S. THE PROPERTY OR ADJOINING PROPERTY., .......... .......... : . i I :. °,AT y- a s'Ju:afJUIN:Xju vT) POO lfi,H'�F;LT#i SEHV,.8c l ...... X1.1 4�fC �'Na 4IFtViIENTA[ f fAjCT?I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . _ DATE: 'AREA; C� 17 TANK,PIT OR SUMP INSPECTION BY ATE I I FINAL INSPECTION BY TE_ I rZC/} ADDITIONAL COMMENTS:' - IY ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK CASH RECEIVED BY DATE SR!P`ERMIT NUMRER INVOICE# Z:2 5joa--