SU0006046 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH 'ICES �r ENVIRONMENTAL HEALTH DIVISI..r P.O.BOX 38B,445 N.SAN JOAQUIN ST., STOCKTON,CA 952010388 (209)4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ (Camplat8 in Tripl'icata) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENV�IRO.N7MEwNTAL HEALTH DIVISION. n JOB ADDPESS;Oft AP U CITY L//]U-� 'A'Kuf'J LOT SIZE`""vim^/ OWNER'S NAMEADDRESS /> P !/ PHONE 3(0 COM )RACTO ADDRESS 1`� r 7 UCa �3 Z G PHONE SUBCONTRACTOR ADDRESS LICI PHONE TYPE OF SEPTIC WORK'. NEW INSTALLATION CREPAIRJ-.l.TI..,M, DESTRUCTION❑ _ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEAC TESTI..1 I HOW MANY TI�� A,pil..Bon i l INSTALLATION WILL SERVE: RESIDENCE COMMERCIAX OTHER❑ / F—�1 NUMBER OF LIVING UNITS: NUMBER OF REMO, b: NUMBER OF Ba1PLOYEEi: CHARACTER OF SOIL TO A DEPTH OF S FEET: /SUMP 501y CHARACTER: / WATER TABLE DEPTH SEPTIC TANK/GREABF TRAP TYPE/MFG CAPACT'�(p�Cl NO.COMPARTMENTS EN � PKG TREATMENT PLANT 13 [NSTANCE TO NEAREST: WELL /O 'S-- PRO C ? FOUNDATION PERTY UNE. 5 1F LIFT STATION 13 SIZE TYPE OF PUMP ySAND OIL SEPARATOR[ENCLOSED SYSTEMI LEACHING LINE XT NO.6 LENGTH OF LINES I- DISTANCE TO NEAREST:WEU D f FOUNDATION /Q PROPERTY LINE f RLTM BED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH DEPTH DISTANCE TO NEAREST:WELL.FOUNDATION PROPERTY LINE sfd.��NGTHr, /f T SEEPAGE PTS X-'- 912E NUMBER DISTANCE TO NEAREST:WELL- D'f FOUNDATION O !f PROPERTY UNE � — SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WRH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOIKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM SATIO+LN SLAWS CALIFORNIA." THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIREE/D/INS CTIONS. COMPLETE DRAWING BELOW. SIGNED X v( TITLE: I 1 DATE: R PLOT AN(DRAW TO SCALE)SCALE -to , \ V 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OIJTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. �. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS, THE PROPERTY OR ADJOINING PROPERTY. PAYMEN, .. .... I .... I AUG 17 1995 SAKI JOA Pug4.rC`. QUtNCc,Li+arY.. aNVIRpN JiWfhl.3ERhICES M NL� � T EALTH flIVtSION /' g I I � _ FOR DEPAATMENT USE ONLY APPLICATION ACCEPTED BY I DATE: V / / I AREA: I _ �y/_,' l TANK,,.i�I.�R SUMP INSPECTION BV CS DATE 5 / L✓FINAL INSPECTION BY� pcN � I l I ADDITIONAL COMMENTS: ACCOUNTING ONLY. AID- FAC/ PE CODE FEE INFO AMOUNT REMITTED tCHEC #�Ovmlly DATE irl:PFAMIT NUMBER INVOICE l v