Laserfiche WebLink
APPLICATION FOR LIOUIO WASTE PERMIT <br /> SAN JOAOUINtOUNTY PUBLIC HEALTH SERVICES' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 396, 445 N. SAN JOAOUIN ST.,STOCKTON, CA 96201.0368 <br /> (209) 468.3420 <br /> NON•REFUNOABLE PERMIT.EXPIRES I YEAR FROM DATE ISSUED <br /> (ComPlntn in Ttiplkato) <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 I <br /> APPLICATION 18 HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBE[). THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN 'I <br /> D.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,F MRONMENTAL HEALTH DIVISION. <br /> d <br /> JOB ADDRESSIOR A f r <br /> C— LOT SIZE �f <br /> OWNER'S NAME + <br /> AODRESS " <br /> CONTRACTOR PHONE ~(r— <br /> ADDRESS LICA'/ PIONE p 310V,�W 'P- <br /> SUB CONTRACTOR ADDRESS <br /> LICfP <br /> PHONE <br /> � I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RFPAPUAD61TION DESTRUCTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED 1F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING) - q <br /> PERC TESTpI 1 f NOW MANY <br /> APPlioetlon if <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL❑ OTHER ❑I <br /> NUM$ETI OF LIVING UNITS:_ NUMn6S OF BEDROOMS; � NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET> PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> 1 <br /> SEPTIC TANK/GREASE TRAP ❑TYPElMFG I CAPACITY NO.COMPARTMENTS _ y <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST;i WELL10 CJ FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMPSAND 04L SEPARATOR{ENCLOSED SYSTEM) /� G r} <br /> LEACHING UaNE ❑ NO. LENGTH OF LINES_ N O - � DISTANCE TO NEAREST:WELL FOUNDATION J6 -PROPERTY LINE .� <br /> FILTER BED ❑WIDTH LENGTH _)(DEPTH DISTANCE TO NEAREST:wELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH i{ DEPTH DISTANCE TO NEAREST:WELL FOUNDATION <br /> ��_ PROPERTY UNE_ - •I _ <br /> SEEPAGE PITS ADEPfH SIZEJ6�NUMBER_DISTANCE TO NEAREST:WELL,r a� POUNDATFONC�.PROPERTY LINE-D <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST.WELL FOUNDATION PROPERTY LINE ! <br /> DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> r ' <br /> li <br /> I HEREBY CERTIFY THAT!HAVE PREPARED THIS APPLICATION AND THAT THE WORKi.WILC BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OA(NNANCE8 AND STATE LAWS,AND RULES rte) <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS 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 <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE!PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS I6SUEb,1 SHALL EMPLOY PERSONS SUBJECT TO /V <br /> WORKMAN'S COMPENSATION LAWS OF CALIF IA.' THE APPLICANT MUST CALL 24 Hot*&IN ADVANCE FOR ALL REQUIRED INSPECTION&: COMPLETE DRAWING BELOW, <br /> SIGNED X � <br /> TITLE! - DATE; <br /> I <br /> PLOT PLAN(DRAW TO SCALE)SCALE ^to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSE[) <br /> 2, OLITUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. - EXPANSION F 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 1 <br /> INCLUDING COVERED AREAS SUCH AS P TIOS,DRIVEWAYS,AND WALKS. - THE PROPERTY OR ADJOINING PROPERTY. <br /> � . <br /> .. <br /> 1� <br /> DC7 <br /> w._ <br /> :. <br /> Z.�} <br /> ...... ...... <br /> r <br /> if <br />