SU0004271 - Laserfiche WebLink

Home Browse Search

lPay, PPLICATION FOR LIQUID WASTE PERMIT SAAJOAQUIN COUNTY PUBLIC HEALTH SERVICES'". ENVIRONMENTAL HEALTH DIVISION P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (2091 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Complete in TriplkEt/) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMA INSTALL THE WOW DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPME NT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMMENTAGL�HEALTH DIVISION. JOB ADDRESSIOP APNI ��Y�.S 2 16 r� 4,",C) `-C_� CITY LlY✓C.�L'V I�� LOTSIZE �A OWNER'S NAM ��r,P�y-.�-Il A T/ ADDRESS 5;1 yn If- R10NOR CONTRACTOR (T/TTL--T//y �^/ ADDRESS LIC/ PHONE SUBCONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAR/ADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of BUILDINO.1 PEEL TEBTIJ 1 1 HOW MANY C/. APtllo.eon s INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER okQ (J•[IIyNTf- –J CT NUMBER OF LIVING UNITS: / NUMBER OFF BEDROOMS: NUMBER OF FMMOVEIES CHARACTER OF SOIL TOA DEPTH OF 3 FEET: C Z PITISUMP SOIL CHARACTER:'', I-}'^y/lam_ WATER TABLE DEPTH �� /• "I11 SEPTIC TANKIOREASE TRAP ❑TYPL/MFO �D Nf�,✓L L. '�` CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑�S/IZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) / � , LEACHING LINE NO.B LENGTH OF LINES '/ — q 0 /07 ' DISTANCE TO NEAREST:WELL V 1 FOUNDATION J`O 1 PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS 1' OEPTH ,?Ll SIZE NUMBER DISTANCE TO NEAREST:WELL &0 tZ ' FOUNDATION S'�/ PRDPERTY LINE SUMPS C1 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPFH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE — I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.ANO RULLB (N AND REGULATIONS OF THE BAN 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,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWMAN'6 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOWB HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP LAWS OF!(C�AL/ff/O/�N1 )THE AP%I^CANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REQUIRED INSP£CAONe. COMPLETE DRAWING BELOW. [�] m SIGNED% �� /2-{jr / TITLE: i,{)r l� DATE:A /— / PLOT PLAN(DRAW TO SCALE)SCALE 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY".ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE P PP`EERTY OR ADJOINING PROPERTY L /��j/j� cJ �Z r� Lb —72 `J E��ey M A PA v[vjEfM e X OCT _.. Sato J0",4UIN.9.GUNTV I ON&I HEALTH SERVICES <NVIRONht&N PAL NpALTH 01VIS)(iN FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA: –Z— TANK. �/ C TANK,RT OR SUMP INSPECTION B�IY�/� ('j 1 '/D1EAT / / FINAL IN��yyySPECTION BY � -n� , �\(J� DATE /O / g / 17 ADDITIONAL COMMENTQv. �X!]MMI�V�-N, �/A'J 1✓. .(J ,1% _ �L�LtT /y' -) ZIA Y'�/,(�FiJ� (IVjf' ' IT vy0 ACCOUNTING ONLY: AID/ FAC# ,S PE CODE FEE INFO AMOUNT REMITTED CHECKS/ 94 RECEIVED BY DATE eR I PERMIT NUMBER INVOICES �tj