SU0004530_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 )209) 4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Camp Mi in Diplk#te) APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMRIANCE WITH BAN r JOAQUIN COUNTY DEVELOPMENT TRUE.CHAPTER 5-1110.3 AND/THHE_STANDARDS OF BAN JOAQUIN COUNTY COU,NT'Y PUBLIC HEALTH SE�R(VJIC/SES,ENVIRONMENTAL HEALTH DIPISION. JOB ADORESSMR API# / 3 � / ✓�'LC!/L'P/+`�� /�Jiy&� T. ACFTY �/ "'� LOT BIZ / OWNER'S NAME LK Q ADDRESS /75GG 5''�fL. CONTRACTOR 'YALa /JL ADDRESSIZ I G• 2//�' LIC,`� [ 7 S�RIONE7"TY3-S JY 3 SUB CONTRACTOR _ADDRESS LIC# PHONE Ne TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 10 AVAILABLE WITHIN 200 FEET OF BUILDING.) MC TESTW I 1 HOW MANY APNleeuen r INSTALLATION WILL SFFW: RESIDENCE 11COMMERCIAL�o OTHER 11 NUMBER OF LIVING UMTS: NUMBER G�OLLF S�EUROOMe: NUMBER OF MPLOYEES: 30 CH OF 601E TO A DEPTH OF 3 FEET: L.�L� PIT//J6VMP SOIL CHARACTER: JYC WATER TABLE DEPTH OFFING TA EASE TRAP ❑TYPE/MFG CtrxClt /aL CAPACITY d NO.COMPARTMENTS ` EATMENT RANT❑ DISTANCE TO NEAREST: WELL—d0�'F FOUNDATKIN iO PROPERTY LINE .� LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR)ENCLOSED SYSTEMI R LEACHING UNE ❑ NO.L LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY RINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYLINE MOUNDED ❑WIDTH LENGTH DEPTHDISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I SEEPAGE RTD -DEH PTS12E LQ �� NUMBERJ//,,--CC�DISTANCE TO NEAREST:WELL v Uf FOUNDATION.25 PROPERTY LINE 3O / #UMPD ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE d6roDAl roNOO ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I NAVE PREPARED THIS APRICATION AND T AT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAWIN COUNTY ORDINANCES AND STATE)AWB,AND RULES I AND REGULATIONS OF THE DAN JOAQUIN COUNTY.HOMEOVRIEROR ENBED AGENT'S SIGNATURE CERTIFIES THE POLLOWING:'ICERTIFVTHAT IN THE PERFORMANCE OF THE WORK FORWHICH THIS PE ED,16 NOT EMROY ANY PERSON IN BUC A ANNER A8 TO BECOME SUBJECT TO WOFKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 1 SUB RACTING IGH TV CERTIF T LLOI ANO:9 CER 1 THAT IN THE PERFORMANCE OF THE WORK FOO WHICH THIS PERMIT IS ISSUED.I SHALL EMROY PLR89N8 SUBJECT TO WO AN'6 COMP: N CALIPOR IA.' IRN1 ! WT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION#. COMPETE DRAWING BELOW. �/�1'--.. • 1 SIGN D% TITIE:tAf�.4 DATE: ROT RAN B)RAW TO SCALE)SCALE 1. 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 COWFIED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 1 LAR a� I tt� g N �hr JCC 1 _.I ReaeR