Laserfiche WebLink
30 <br /> f� IZ <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N- SAN JOAQUIN ST., STOCKTON, CA 962010368 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> M mplam in Trip6eam) <br /> APKICATON m HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLIDATION IS MADE M COMPLIANCE WTN SAN <br /> "AWN COUNTY DEK'L7OMENT TTITIN',CHAPTER 9-1110.3 MO TV <br /> STANDARDS aO.F SAN JOAQUIN COUNTY POBLIC HEALTH SEA <br /> ES.ENWR•ONNNME�NTTAL HEALTH DFAMN. <br /> JOB ADDRESSOR APNY� A �/� �� �/V W� �OO (.7 <br /> CITY / ,/C YN• �-W <br /> may. ('� �/ LOT BIZE�YT CJ P� <br /> OWNER'S NAMFy rO KP3 F'4Y/fi'] ADDRESS sus W /(, �� �c� ^� <br /> PHONE / <br /> coNrwstDR(YEU/li y'I�f/G�4-Pi m(F- �A)c wDREssfd BaX /3g -rho FHONE <br /> SUB COMIIAE,TOR ADDRESS LIC! PHONE <br /> TYPE OF 119710C WONT: NEW INSTALLATION R MMADpTRON ❑ DUTIILN:TION ❑ <br /> MO SEPTIC SYSTEM KRMTTTED IF PUBLIC SEWER 15 AVAILABLE WTHIN 200 FEET OF BUILDING.) PERC TESTI-11 I HOW MANY <br /> H�( Appnwtlon/ <br /> INSTALLATION MILE SERVE RESIDENCEL COMMERCIAL 0 'J OTHER ❑ <br /> NII M OF LIVING IIMTS:� NtPoN `ENCO,f B•EOF&GOM6: V NUHBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FfETaJ2/^"�1 .1�9M PITISUMP SOIL CHARACTER: WATER TABLE DFSPTM <br /> SEPTIC TANBARFILLE TRM �TYFE/1.IFO FFAJIC�3 CAPACITY /60aZ <br /> W.COMPARTMENTS <br /> PRG TREATMENT KART 0 DISTANCE TO NEAREST: WELL FOUNDATION P'iOMRTY UNE <br /> LET STATION 0 WE TYPE OF FVMP _6N D OIL SEPARATOR(ENCLOSED SYSTEM( !- <br /> LFACNNG UNE NO.L LENGTH OF LINES CA.. DISTANCE TO NEAREST:WELL/OO T' FOUNDATION K10KMY LINE `J <br /> FILTER BED 0 WROTH LENGT I ETH Q Q DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED 0 WIDTH LENGTH DI:PTH DISTANCE TO NEAREST:YJEFL FOUNDATION PROPERTY LINE .� <br /> SEEPAGE KTa 0 DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE G <br /> LUMPS 13 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE O <br /> OISPOM PONOa 0 WIDTH LENGTH DEPTH DISFANCE TO NEAREST:WELL. FOUNDATION P OKRTY UNE dL(' <br /> I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APRICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SMI JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES ` <br /> AND REGULATIONS OF THE SAN JOAOUIN COUNTY.NOW OWNER OR LICENSED AGENT'SSIGNATURE CERTIFIES THE FOLLOWING -I CERNFYTHAT IN THE KNFE) MANCE OF THEWORK FORWHICH <br /> THIS PEAMrt IS m6UE0,1 SHALL NOT Y ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORCMAN'6 COMPENRATION LAWS OF CALIFORNIA.- CONTRACTOR'S NNENG OR T <br /> SUB{ONTRACTI GNATURE CERT( IES T FOLLOWING:-I CERFIF�YT THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS KRMT IS ISSUED,I SHALL EMMOY PERSONS SUBJECT TO / <br /> WORKMAN" MKN AT i LAW'- CAL( 1A.' TME��p''UC''A I�1�RLI////IYY••AA(UST CALL 24 HOURS IN ADVANCE FEAR ALL <br /> ��REy/O_URED�(I/,N�SPECTIONS. COMKETE DRAWING BELOW', Tf' <br /> SIGNED E�^�I�I�L�It�'1 TITLE:LS>.n^i/,LCIU� DATE: OC� SS <br /> MOT PLAN(DRAW TO SCALE(SCALE <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROKRTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE Of THE FIOMRTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISFOSAL SYSTEMS. <br /> 3. DNAENWNFO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, fi. LOCATION OF WELLS WITHIN RADIUS Of ONE HUNDRED FIM FT ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DPoVEWAYS,AND WALKS. THE PROKI TY OR ADJOINING PROKRTY. <br /> SKEW <br /> � I well vF`YP � <br /> D �s� <br /> 6 <br /> R � 0 IY4.�fY SN-f'G g' <br /> PAYMENT <br /> RECEIVED <br /> MAR 21995 <br /> SAN JOAQUIN CQUNTY <br /> PUF1_if HE LT11 SERVICES <br /> ENVIROjtlMLNTAL HEALTH DNI ION <br />