SU0001242 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQI110 WASTE PERMIT j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE: STOCKTON CA 95202 (209) 468.3420 p llI NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ! f -7. _-O -3 IComphte In TriprmatB) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB AOIKiESBA)R APNR CITY S 1 I . ��`-� LOT SIZE OWNER'S NAME )} ADDRESS PHONE 4 CONTRACTOR WA EALL ChUst ADDRESS13_ .Sa _ �. i ( V"T/ UCN "-)-lPHONE S SUB CONTRACTOR ADDRESS ----77--"�~ IUCI PHONE 111 TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITWN ❑ DESTRUCTION WO SEPTIC SYSTEM PERMITTEO IF PUBLIC SEWER IS AVAILABLE WFTHIN 200 FEET OF BUILDING.) PE9C TEST191 I 1 HOW MANY AppNastlon N INSTALLATION WILL SERVE: RESIDENCE M—OMMERCIAL❑ OTHER ❑ NUMBER OF WINO UMTS:-,. NUMBER OF BEDROOMS:�� NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PFTISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT BTATION 13 SIZE TYPE OF PUMP SAND OIL SEPARATOR 1ENCLOSED SYSTEM) LEACHNo LINE 11 NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE E3 WIDTH— W MOUNDED LENGTH DEPTH DISTANCE TO NEAREST; ELL FOUNDATION PROPERTY LINE SEEPAGE ATB ❑DEPTH SIZE _ NUMBER DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY LINE BUMP$ ❑WIDTH LENGTH DEPTH - DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DIBPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 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 OWNERORUCENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEFMFYTNAT IN THE PERFORMANCE OF THE WORK FORWNICH THIS PERMIT 18ISBUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO VMRKMAN-0 COMPENSATION LAWS OF CAUFORMA.- CONTRACTOR'S HIRING OR SU&G IND SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN• COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&. COMPLETE DRAWING BELOW. I { SIGN ED �� C -DATE: .- PLOT PLAN LDRAW TO SCALE!SCALE_ •to 1. NAMES OF STREETS OR ROAOS 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.OH u INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY -.- { ° - - - ....,., .......... - FF S I xisLJ .. ..... ,- Uy• _ . .. ....... r.. . . .... ... ....... +y ` / {l+1). i h ...... s . .... . - . .SRN JQt«r�JlN t;CtUllT•�` "�:•�-," - Nr'11 .a FOR DEPARTMENT USE ONLY S 3(4 APPLICATION ACCEPTED BY - DATE: DA 2-101 AREA: TANK,PTT OR SUMP INSPECTIOLI BYE -may. DAT l�1�� FINAL INSPECTIO BY DATE ADDITIONAL COMMENTS: �� i.q, S c N___e:Q I LL ACCOUNTING ONLY: AIDN FACN PE CODE FEE INFO AMOUNT$IPAITED CIIEC ABH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE N L Lf Puts.Heatth Serv.-EnAro.174(3M) 6a l l -PG r 1 --\a` vis Cd y&8-_ 3 y o