Laserfiche WebLink
PLICATION FOR LIQUID WASTE PERMIT <br /> SAN� AOUIN COUNTY PUBLIC HEALTH SEALS <br /> L ENVIRONMENTAL HEALTH DIVISION d'+�" f�6 <br /> T"i •d ", a 304 EAST WEBER AVENUE, STOCKTON, CA 95202 G --•' 0 a <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICamPlata In Triplicate) <br /> APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOM DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT THU.CHAPTER 81110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY WBUC HEALTH SERVICES,ENVIRONMENTAL HEALTHHNVISION. <br /> JOB ADDRESSIOR AM# I�! 0 ! �e� `G' CNY19� Q/{ ,T • pLOT SIZE_ <br /> OWNER'S NAME B qC P1 G N I_�J 14 ADDRESS R NE !13 l- 13 <br /> CONTRACTOR Mon+, t.c (ot-I ADDRFSSA,'( w ()Q� 5r ucr oNEy(�--"�'t-) <br /> @U@CONTRACTOR ADDRESS UC# PIONF <br /> TYPE OF IEPTIC WORN: NEW INlTALLATION ❑ REPNRIAnNTION ❑ DGTRUCDON ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF Me.0 SEWER 1@ AVAILABLE WITHIN 200 FEET OF BUILDING.) PFRC TFSTbI I 1 HOW MANY <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTITER ❑ <br /> NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS: NUMBER OF EMKOYM: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_ MISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANX20REASE TRAP ❑TYPE?AFO CAPACTTV NO.COMPARTMENTS <br /> MO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> RIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> MOUNDED [IWIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATMN PROPERTY LINE <br /> SFEPAOE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> SUMPS ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN"AMIN COUNTY.NOME OWNER ORUCENSEO AGENT'S WONATUPE CERTIFIES THE FOLLOWINU:'I CERTIFYTHAT INTHE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO MWMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WMI(MAN'S COMPENSA ON TAWS OF CALIFORNIA.' THE APPLICANT MUST 'ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPETE OnAWINO BELOW. <br /> SIGNED X TITLE: <br /> GL�L� �YVG{2 DATE: !/-2-'3 C <br /> pD• <br /> POT PIAN SJRAW TO SCALE)WALE_�_ Ic <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROFMSEO <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANBMN OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRVEWAYB,AND WALKS. THE PROPERTY OR ADJOINING P110PERTY. <br /> NOV 2 31MO <br /> IAN JOAQUIN COUNT Y <br /> PWALIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> FOR DEPAR ENT USE ONLY <br /> c L DATE: AREA: 2/Z <br /> AMICATION ACCEPTED BY r /' <br /> TANK.M OR SUMP INSPECTION eY DATE I l FINAL INSPECTION BV DATE / v <br /> O�— <br /> ADDITIONAL COMMENTS: <br /> �0 r <br /> ACCOUNT) ONLY: AIDS FAC# <br /> PE CODE FEEINFO AMO UNT.MI ITED CIIEC ASH <br /> RECEIVED By GATE ARTPERMIT NUMBER IMVOILEI <br /> IZ.°Oa4�� <br /> Pub.Health Sew.-Enviro.174(3/96) A <br />