SU0003053 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �( P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201368 f 12091 4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (CBmpIB61 In TriplkttE) APPLICATION IB HEREBY MADE TO THE SAN JOAOVRI COUNTY FOR A PERMIT TO CONSTRUCT ANOOR INSTALL THE WORK DESCENDED. THIS APPLICATION Ig MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI CITY LOT g1ZE OWNER'S NAME bA IJ ADDRESSPHONE CONTRACTOR 11 // /J ADORES$ / -� > LIC! PHONE / OUR CONTRACTOR �l YLi /' /��(_ ADORE$$ ry�� 2/Q /1 '� LIC11 ��S�f� PHONE ,SJ � TYPE OF SEPTIC WORK: NEW INSTALLATION REPARVADDITION ❑ BNTIUCTON❑ '\ NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING) PMO TNTDI t 1 NOW MANY V tl MRIeABan• R. INBTAWTON WILL SERVE: PE$IDENCE 11COMMERCIAL ❑ OTHER El ��/� ��.�_ � NU OER OF UVINO UMTS: NUMB9R OF BEDROOMS: NUMSGR OF FMROVM: / 7 CHARACTER OF BOIL TO A DEPTH OF 3 FEET: /j RT/BUMP SOIL CHARACTER: �I WATER TABLE OEPTFI /� A f� SEPTIC TANK/OREASE TRIM 0 TYPE/MFO CAPACrrV 1a NO.COMPARTMENTS Ash G` PRO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL Z G+F'-r FOUNDATION /O 1� PROPERTY UNE C LIFT STATION❑ SIZE TYPE OF PUMP RANO OR SEPARATOR(ENCLOSED SYSrEMI (� LEACHING UNE 4S NO.SIENOTH OF LINES /—�Df/ FT M"ANCETONEAREOT:WELL CAbf VNDATION /(l�7•DEIDPERry UNE �SCJC)T FT FILTER SFO WIDTH LENGTH DEPTH DISTANCE TO NEARER:WELLT'FDVNDATIONPigpERfY UNE F MOUNDED 11 MOTH LENGTH DEPT# DISTANCE TO NEAREST:WELL FOUNDATION POIOPEIRTY UNE SEEPAGE RTS 0 DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE am" 0WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS 0 MDT" LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P110PERTY UNE I HEREBY CERTIFY THAT 1 HAVE FWPAPEO THIS AMICATRIN AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULE$ AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CEW IFYTHAT IN THE PFAMRMANCE OF THE WORK FOR WHICH THIS PERMIT Ig ISSUED,I SHALL NOT EMPLOY ANY PERSON IN OUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB COWFACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT Ig ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUREO INSPFOTONB. COMPLETE DFAMNO BELOW. SIGNED X ��.,�1 � TITLE- DATE: ROT PLAN(DRAW TO SCALE)SCALE_-m 1. NAMES OF STREETS OR SCADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOOAL SYSTEM OR RgPoSED 2, OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 1. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING ROPERTY. j - - ►- ov 1 ---1 7/-,),-<- 17-7 1 l)U 13' 1 1995 - I +ILIr IE/IL f.N Sl r,di I . '. 1VVfti ,!xiM1A! I I 4 hlt.dl 1 hl DIS I ((1 1 FOR DEPARTMENT UBE ONLY I 1( (, (,7 APPLICATION ACCEPTED BY yv yw, DATE- V �3 �9T S �I AMA: Z,1 L U T TANK,RT OR BUMP INSPECTION BVS ./ GATE ( / FINAL INSPECTION BY .,[/LAM 4'v DATE 1O / ADDITIONAL COMMENTSo ACCOUNTING ONLY: AID$ FAC# PE CODE FEE INFO AMOUNT REMITTED CHEC (CASH RECEIVED BYOATS M/PERMIT NUNSGR INVOICE$ 0 Lhuz'L. ' "0/3 9 _1 .1 `e aa38oa