SU0004212 - Laserfiche WebLink

Home Browse Search

ip•- �o APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES O ENVIRONMENTAL HEALTH DIVISION P,O, BOX 38% 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW(DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# J , /�l JAI J / Aj 9 . p� CH,/_ -r-j �1 J, ( LOT SIZE` OWNER'S NAME ) � � _! I ( �J AJ ADDRESS (�'' r' (J / { 7� �'� PHONE CONTRACTOR Y--�•I 1� ! {W L (('�J` ADDRESS ,•`(S�3 SO l L�( ! I� 11LIC! � � � PHONE SUBCONTRACTOR ADDRESS UC# 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(.)I 1 HOW MANY Appliondon# INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL'a OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.d LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FnUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SU`MP6 ❑WIDTH LENGTH DEPT14 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 WOW(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH ^ ' T141S 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 N SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN OMPENSATI LAWS OFC LIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOLMAIED INSPECTION$. COMPLETE DRAWING BELOW. _. SIGNFD X TITLE: /"- L'/4 l�� ) DATE: Z PLOT PLAN(DRAW TO SCALE)SCALE 'to C 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED F 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. 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, h O ..i .. '.... i.. -.. . ..: :. _...'.. J... _ _ _C . .. . CSFNM kx1r) - -- __ use &' l , AJ .. 5 f h , . �rlvG .____R WRMT OCT 0 9 1997 INC UN1Y ll o Ot ! ', �.l...,�1 1 H[7rJMEN=4 SE VICE Sl(Ir. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY � �_fij/)�-� _. l C: �-� O DATE: AREA: PI TANK, T OR SUMP INSPECTION BY / GATE / / FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: (/ eeR(,IJ (Jy�, ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK#! ASH RECEIVED BY DATE8Ti/Pf7iMIT NUMBER INVOICE! a �r� 10 -11lei o419s5