Laserfiche WebLink
APPLICATION FOR LIOUIO WASTE PERMIT <br /> PUBLIC HEALTH <br /> L HLTH <br /> COPY 304 EAST WEBER AENVIRONMEVE UE,SSTOCKTOIN, CA 5I202S <br /> /7y2�7 (209)468-3420 <br /> [L, ,^,/n��7, ,,NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> tOwn L. /1 Agli � IComplato In Triplicate) <br /> APPICATION IB HEREBY MADE TO THE SAN JOADUIN COUNTY FOO A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPIANCE WITH BAN <br /> "AWN COUNTY DEVELOPMENT TRUE,CHAPtER 0-1110.3 AND THE STANDARDS OF SAM JOAWIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AUDBESSMR ARNP _ /A''A Ctry 2 e-d- LOT&2E � <br /> ..'a NAME�V 6 `� ADDRESS PHONE //77��� <br /> CONTRACTOR i�+� �A6' /AI`:— ADURESer <br /> SUBCONTRACTOR ADDRESS lK1 RHINE <br /> TYPE OF SEPTIC WORN: NEW BUITAULKMM ❑ mae aaw"WTION ❑ DESTMUCT5N <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEIC TEaT411 1 NOW MANY <br /> AppSwbn I <br /> INSTALLATION WILLEE:BNWSHIENCE[3COMMERCIAL❑ OTHER❑ <br /> NI M OF LANG UN14: NUMBER OF BEDROOMS: NUMBER OF SMIN OYEEA: <br /> CHARACTER OF SO VTPT <br /> O A DEH OF 3 FEET: WISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEIRTC TANRI0IFABE TRAP ❑TYPE)IAPO CAPACITY NO.COMPARTMENTS <br /> PEO TREATMENT PANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OR SEPARATOR(ENCLOSED SYSTEM) <br /> LEACMNO ONE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY ONE <br /> FILTER BED ❑VADTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY ONE <br /> MOUNDED ❑WIDTH IENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SEEPAGE NTS ❑DEPTH-SIZEIS <br /> NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY ONE <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION POPERTY ONE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PPUPERTY ONE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN JOAWIN COUNTY ORDINANCES AND BTATE LAWS.AND RULES <br /> AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT INTHE PEROWANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHAT NOT EMPUOyAIAY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIPNO OR <br /> SVS-CONTRACTING SIGNATURE CERTIFIES TI E FOLLOWIN . ERTIPY THAT IN THE PERFORMANCE OF THE WOR(FOR�ICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION lN4(e OF CAII ONIIA.' THE APP CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL 11E URE)INSPECTIONS. COMPLETE OnAm"BELOW. <br /> SIGNED X 1 TRUE: GATE: a� <br /> ROT RAN DRAW TO SCALE)SCALE -U, ``I\ <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF AL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS BUCH AS PATIOS.ONVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> 7V ( U <br /> Pf <br /> � FX%71Al�cc (��pIT t7tk SEP 241998 . <br /> FOR DEPAPTMENT USE ONLY2I <br /> !moi" Q <br /> APPLICATION ACCEPTED BY //�" A. DATE: <br /> TAM:,PIT OR SUMP INSPECTIOH BY �y DATE I l FINAL INSPECTION BY ZZ l l JU <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: ADF FACE <br /> PECODE FEE INFO AMOUNT REMIITED ASN REC BY DATE SR I PERMIT NUMBER INVOICE P <br /> s`7 D16 <br /> Pub.Health SEN.-Enviro.174(3/96) <br />