SR0085029_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT cook v SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, 3T OMN, CA 95201-388 (2093 469.3420 9MEFUN0 BLE PERMIT EXPIRES 1 YEAR Fl9M DATE I€iUE8 APPUCATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO1OR INSTALL THE WOFK DESCRIBED. THIS APPLICATION In MADE IN COMPLIANCE WITH VN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DMMON. .roe ADOPli88roR APNS•_f�g .4;!/O Oct, ' 1`� cm�"7F,��Jt�'e✓,/��,,�_•�LOT e1LE�,(i OWNER'S NAME✓ ADDREee�j �� - /1 C�Cj Lis PHONE 7/7 6F•'.,2. ,��6,�" CONTRACTOR yi• , .,..J //.�.y E �y=L FeB,ap(y --.--"-i .fid; -ZG; .'—?sai� .; ,�' LIC.-i:�:�QQ6 _ PHONE 9.i�-l8f�sl SUM CONTRACTOR nDDREes LroS PHONE TYPE OF SWTIC WORK NEW 1NBTALLATION ❑ REWAINADOITION� OHTTLA:TON ❑ INO SEFTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILpNO.I P91t4 TESTUi I 1 HOW MANY �{ AFp9AAtlen INSTALLATION VRLL XWVE: RESIDENCIIA COMMERCIAL I] OTHER ❑ NLNIMER OF UNNO UMTS: NIwNEl Of SE-DROOMS: NUVAM OF MAKOYEES: CHARACTER OF 608.70 A DEPTH OF D FEET: CrA T FFISVMP SOI. CHARACTER: t'`C. ti/ WATER TABLE DEPTH .zi D / SE"M TANKMIFA+E TMP 13 rms rca Y __ CApACRY /9CJU lam[/ NO. COWMAIRTMENTS_SL PRO TREATMENT RANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE SIFT STATION ❑ d�G1M TYPE OF PLNAP BANG OR SEPARATOR S:NCLO6ED SYSTEM) LEACHING UNS Ax MT. S [ENGIN OF URIEQ_, �0 OISTANCE TO NEAREST: "114� fOL*OATION / QJPROPERTY LINE FILTER SED E3YAO7H LENGTH-- DEPTH DISTANCE TO NEAREST; WELL _ FOUNDATION PROPERTY LME MOUNDED EJ WIDTH IENOTN DEPTH DISTANCE TO NEAREBT: WELL _FOUNDATION PROPERTY LRE SDEPAOE PIT. InI DEPTH�� SUES/l NUMBER_' L DISTANCE TO HEA LEST: WEIL1LCI L FOt"lAT;ON. pRpPpDY L f BUMPS O WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL_ POUTmATION PROPERTY LINE DitptAL bNDt Q WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNOATNIN PROPERry UNE I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TH� WORK Not BE DONE IN ACCORDANCE WITH SAN JOA -14 COUNTY OIpIMANCES AND STATE LAWS, AND RULER AHO REGULATIONS OF THE SAN JOAOUW COUNTY. HOME OWNER OR LICENSED AOENT'S SMINATlR1E CEKM ES THE FOLLOWINO: `I CERTIFY THAT IN THE PEfFOTSAAHCE M THE WORK TOR WHICH THIS PERMIT IB ISSUED, I WALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WOTKM/W'S COMPENSATION LAWS OF CALWOREIA.' CONTRACTOR -41 MIMING an SUS�ONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN01 T CERTIFY THAT IN'THE PERFORMANCE OF THE WC.fK FOR WE:CH THIS PERMIT M ISBUED, I WAIL EMPLOY PERSONS BU6JECT TO WORKMAN'S COMPS SATN)N LAWS OF CALIFORNIA.' THE APROR ICA14T MUST CALL 24 HOURS IN AVVANCS FALL RlO1ARSD ItMPSC7lOM1. COMPIFTE DRAWING BELOW. SIGNED X j - DArF: 'mss PLOT PLAN RMAW TO SCALEI SCAi.E - to 1. NAMES OF STREETS OR RDAOS NEAREST TO OR 90UNDWG THE PROPERTY, �, 4. LOCATION OF HOUSE 9EWAOE DISPOSAL SY9TEM OR PROMSED 2. OUTLINE OF THE pMPERTY, WITH DIMENSIONS AND NORTH TYRECTON. EXPANSION OF SEWAGE DISPOSAL SYSTFMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED STRUCTURES, B, LOCATION OF YELLS VM MN RADIUS Of ONE HUMORED FIFTY FT. ON INCLUOINO COVEPW AREAS SUCH AS PATIOS, IXSVEWAYS, ANO WALKS. THE PWPERTY OR ADMMM F%MM. �Roo,5e/ l ' coo ID /�,•Dr S~LICHEALTHSERV t5.:.. .i, .. FNVINCobNTy R'JN?A.`.NTALLIEAL7)i•DIVISIOti 1 ' .... ... .. r.... .. ... .... �\-�� •� FOPO TME:i U/E OILY �//7I) %Au0 AJP�KIICATION ACCEPTED BY 11 ."Iy�1/�YWrjl. �y // DATE: / f 2— /nryc, fT 0.SUF9PIN6PECJTI^ON/SY Uj-� ATE—/-N/+y.LINESPFCTI N/; SO Y�7 �f� �I.,✓(�C%/ '` ADDITIONAL COMMENTS:/1121_ �.��lJ 1` TrJ��i/.CWiS"if O_!/-. A`�---*h{/--N "Z �G ACCOUNTING ONLY: AID/ FAC, PE CODE FEE INFO AMOUNT REMITT CHEc ASN RECEYEO BY DATE SR f P@MT NUNfe f? CE P a I ! 0= - 3Eo l �1a514ti S 1 L