SU0000694 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complata in Triplicate) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 19 MADE 1111 COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. / JOB ADDRESS/OR APNN ( ��„ t`,f.L�� 1Q'0 CITY L=Se-GLO Lf SIZE SIubC OWNER'S NAME c b 1 J Q ADDRESSV_ S tu-r, 1 PHONE 0 p.--1 I" CONTRACTOR ,� ADDRESS LIC# PHONE '^y 1 q y SUB CONTRACTOR y t�(C-C� y'("C ADDRESS j r� �� L9 Li`d UC/ G Qq S�N PHONE TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(s)I I HOW MANY y - Apoloetlon # INSTALLATION WILL SERVE: RESIDENCE LJ COMMERCIAL ❑ OTHER 11 NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: 'I -4T/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) r LEACHING UNE E NO.S LENGTH OF LINES V DISTANCE TO NEAREST:WELL Inn _FOUNDATIONS_PROPERTY UNE— FILTER BED ❑WIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS PIDEPTH ;�• SIZE 3—�r NUMBEFt__-r DISTANCE TO NEAREST:WELL FOUNDATION `[�1 PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 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 BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES Q AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR -� WORKMAN'S COMPENSATION LAWS LAWS OF CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REyQ�UIRE/D`INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X L/`I J-A-- � TITLE: `• -O�l I 4 DATE: �-�{ (, Q PLOT PLAN(DRAW TO SCALE)SCALE 'to 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 COVERED AREAS SUCH AS PATI08,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. A -- - ---. RECEIVED 7 ...............1�9 APR SRN JUAOUIN CC)ONTY PUBLIC HEALTH SERVICE SIUN ENVIRONMENTAL HEALTH DI l ...... ........... ko .... )i II i .:..... : .. ..:.... . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �0,.,�1- DATE: AREA: TANK,PIT OR SUMP INSPECTION BVDATE / / FINAL INSPECTION'y.. DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FACN PE CODE FEE INFO AMOUNT REMITTED CHECIV/ ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# y'Z04. q7s