SU0000073 - Laserfiche WebLink

Home Browse Search

FN- COPY _ PAl1"El ['; APPLICATION FOR LIQUID WASTE PERMIT REC ' SAN•JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION SEP 6 [000 p O BOXY 304 EAST WEBER AVENUE, STOCKTON, CA 95201.388 MS-40-1d SFNJOAIl��NSEUC(�, (209) 469.3420 iNg�1�.HEAL1h�A`�Hi�1�ISI0fd NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �NVIRONMEN1Al APP KATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRIUCT AND/ORete in INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 1 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# Zhfr i=j T=- I L C- - r r 1 4 LOT SIZE ] Ar OWNER'S NAME -� - f1 F- _ ADDRESS �f)Zr l'1 _ C�< {��-�', C 1:- rG 17 _ N Amt:- , - �1 �• f'S PHONE. c T CONTRACTOR�/�L,.�1<•Y � u�i'T't - ADDRESS-t'hYi i'•i'f1� '-":., t./�. C N C_; 1 IV E E '. LIC' PHONE SUB CONTRACTOR � rLS?•`�}•i`), ADDRESS LIC# PHONE_ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAJPJAD04TION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUII DING.) &-�,s^ av TkiILIT/ ��777III PMC TESTW I/;HOW MANY_ -i INSTALLATION WILL SERVE: RESIDENCE p� APNloetlon# J _ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITE: NUMBER OF BEDROOMS: NUMBER I��%E. FiEY�Jv- � �J CT. tiro OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: I I �Cy- Ti C�tti<)!,A TN PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH I A,��/ 4:: T71Y: SEPTIC TANK/OREASE TRAP ❑TYPE/MFG ------ CAPACITY NO.COMPARTMENTS _ PKG TREATMENT PLANT 11DISTANCE TO NEAREST: WELL FOUNDATION UFT STATION ElSIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) PROPERTY LINE LEACHING UNE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION FILTER BED ❑WIDTHPROPERTY LINE LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION SEEPAGE PITS ❑DEPTH PROPERTY UNE SIZE NUMBER DISTANCE TO NEAREST:WELL SUMPS WIDTH FOUNDATION PROPERTY LINE LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION DISPOSAL PONDS WIDTH PROPERTY UNE LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE THEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 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:-I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR 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'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INBPEC TIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE I LjEDATE: f-IC), PLOT PLAN(DRAW TO SCALE)SCALE 'to- 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 4• LOCATION OF HOUSE SEWAGE DISPOSAL SS. OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, EXPANSION F SEWAGE DISPOSALINRADIUS SYSTEMS. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON THE PROPERTY OR ADJOINING PROPERTY. IR TJ I 11 t7.1� '>] I1/A•AIA� 1�'PROPoSFO/RRIC.1TKkI[,C$[N£NT j IURRCCTON RWD c�� fff�TTTIII J�,JI Li `/ ti ti N 4 it D ...11111111 '. zz 5 C YAN RZ3 �^ /� t !I `�J -� 0 CG VAN ALLEN ROAD cO7 D O — tr i o� _ -u FOR DEP T USE ONLY APPLICATION ACCEPTED BY 1 - *BY DATE: EA:TANK,PIT OR SUMP INSPECTION RYDATE / / FINAL INSPECTION DATE 7 ADDITIONAL COMMENTS: / ACCOUNTING ONLY: AID# FACN PE CODE FEE INFO AMOUNT REMITTED CHECK#/ ASH RECEIVED BY DATE SR/PERMIT NUMBER r 2� _ INVOICE IF