SU0005285 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON REFUNDABEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplatB In Triplicate) LIST APECATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS AP CATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. .�J .108 ADDRESS/OR APII# Y.-2? - ��_ ��S /L. t� CT' LOT 812Fo/�'��j'� OWNER'S NAME tIInej A/DL FADDRESS - c) r✓A ^ � MONE�,��+� CONTRACTORiG LLd,LGrR ADDRESS2 26 L. �/S J/1 PHONE 6-Slrrl Y�(�j SUB CONTRACTOR ADDRESS UCI PHONE TYPE OF SEPDC WORK: NEW INSTALLATION�, REPNRJAUOITION❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PVBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINO.1 PER.TESTIH I I HOW MANY Apptloetlon I INSTALLATION WILL SFRVE: RESIDENCE tp COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UMTS: NUMBER NLI OF BEDROOMS: -OF EMPLOYEEI: /'�I CHARACTER OF 6011 TO A-T/DEPTH OF J FEET: — FIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH !�/ a SEPTIC TANIVOREASE TRAP ❑TYpEIMFO CAPACf1Y— NO.COMPARTMENTS PRO TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL M. / FOUNDATION gf J- PROPERTY UNE LRT STATION❑ SIZE TYPE OF PU M P SAND OR SEPARATOR IENCLOSED SYSTEMI _ LEACHING UT NE 1. NO.B LENGTH OF LINES ^J�'/l/O DISTANCE TO NEAREST:WELLff; fF 1J DATK/N�/f R10PERTY UNE•/t"��j =FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEFTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE NTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS Cl WIDTH LENGTH DEPTH DISTANCE TO NEAFFST:WELLFOUNDATION PP.OKRTY LINE — 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 AND REOIRATIONS OF THE BAN JOAQUINCOUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIE B THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRrD INSPECTIONS. COMPLETE DRAWING BELOW- 9 SIGNED X �A �GG TITLE' A/�l 1 - DATE: d? G PLOT FUN(DRAW TO SCALER SCAT E_ '1' w l 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PLOKRTY. 4. LOCATION OF/ROUSE SEWAGE DISPOSAL SYSTEM OR PfIOFOSED 2. OUTLINE OF THE T'110KRIY.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 PATIOS.DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 70 .. .... r �J 1►, I .... y rl Ir i iV PAYMENT AUG 1 0 1998 SANJOACWjNCOUNTY (Ql - PUBLIC HEALTH SERVICES _. _ ... ... ENVR EALCliD1VI6kiI- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By DATE: V R /W 171? AREA:_ I TANK,PT OR SUMP M6KCTIOf(BV DATE I l FINAL INSPECTION BY DATE ADDITIONAL COMMENTS:1 y�F�yJ AUT 'P>aT i ACCOUNRNO ONLY: AID# FACS PE CODE FEE INFO AMOUNT RUA IT ED IIECK// SH RECENFD BY DATE SR I PEFVAIT NLIMRETI INVOICE! �,► s -0 1 Bio/q� 6165 Pub.Health So--Erlviro.174(3196)