SU0006662 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIIUIO WASTE PERM .USAN JOAQUIN COUNTY PUBLIC HEALkSERVICES ENVIRONMENTAL HEALTH DIVISION SCANNED 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 F if pl . NON-REFUNDABLE PERMIT 9XPIRFS I YEAR FROM DATE ISSUED �I (Complete i6 Trlplieftel APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN ,.I JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. E� JOB ADDRESS/OR APNO y) pw -,ry ` LOT B1ZE.� � j�r OWNER'S NAME ©� s►.Ey ,ADDRESS aytic�- PHONE I CONTRACTOR, t ,, _--j{C,i ADORE88 P0 Z,S LOCI 7 u PHONE SUB CONTRACTOR ADbRESS LIC# PHONE it TYPE OF SEPTIC WORN: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ fl 4N0 SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF BUILDING.1 PMC TESTI@1 I 1 HOW MANY ff�kkF APpevafon• ' INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER❑ I I NUMBER OF LIVING UN17d:�� NUMBEI OF BEDROOMS: NUMBER OF EMPLOYEES: II ^ ji CHARACTER OF SOIL TO A DEPTH O1F--3�FEET: rad PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH . 1 `t` SEPTIC tANK/UREASE TRAP LQ TYPElMFG - '{-L _ CAPACITY, NO.COMPARTMENTS! D- PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLI bAr FOUNDATION� s .i --1 5 ,_ PROPERTY LINE- LIFT STATION gr"NO. TYPE OF PUMP SAND OIL SEPARATOR fENCLOSEO SYSTEM) HI LEACNG LINE BNO,L LENGTH OF LINES 2 I DISTANCE TO NEAREST:WELLN`FOUNDATIOf PRppERTy uNr: S € FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST,WELL FOUNDATION PROPERTY LINE 'I MOUNDED ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE y ©WIDTH UNDATION PROPERTY LINE q \, it SUMS LENGTH DEPTH DISTANCE TO NEAREST:WL3.L FO E !j DISPOSAL PONDS ❑VAOTH LENGTH DEPTH DISTANCE TO NEAREST.-WELLFOUNDATION PROPERTY LINE , 1 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 "'i E AND REGULATIONS OF THE BAN JOAOUIN COUNTY,HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT W THE PERFORMANCE OF THE WORK FOR WHICH - ;i THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON MI SUCH A MANNER AS t0 BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR r SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO EI WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUPRED INSPECTIONS, COMPLETE DRAWING BELOW. I� Ei SIGNED X- TITLE: (cc f DATE: i4 PLOT PLAN 1DRAW TO SCALE)SCALE •Ru i 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED E 2, OUTLINE OF THE PROPERTY,WrTH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. `�E 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED BTRUCTURE8, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON E f INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WA1K8. THE PROPERTY OR ADJOINING PROPERTY. E .. '�T n k Q . p... E :... . .,... .. E ...., ., .. .... .... .... -,... .. _ .. .. - . 1 .,. ., - - ., .. .. ' ;d . ! P LZ.b eau{ ~i PAYMENT : a•'4iC + 6' AUG i i99� . . ... -. . .. ... . ... .. .. .. .. . II r:. li SRN.7(SA UIN CourgTR' .. ...,., -. PUBLIC AF-A H SERVICES :- t ENVIRONMENTAL HF'ALN DMSLC)!� n - - - - - FOR DEPARTMENT USE ONLY !I APPLICATION ACCEPTED BY DATE: AREA: kF �!� ge ELL TANK,PIT OR SUMP INSPEC710N BY lM- r GATE �J f FINAL INSPECTION BY, DgTE °i ADDITIONAL COMMENTS: E E� ACOOUNTIHO ONLY: A19Er FACE p - _ A `I PL CODE FEL:fNFO AMOVNT RFMH7ED HEG /CASH, RECEIVED BY DATE SR 1 PESIRfT NUMBER INVOICE F 3 1 'f Pub.Health Serv.-EnvirO,174(3196) fj l