Laserfiche WebLink
APPLICATION FOR LIQUID WASTE PERMIT <br /> SRN JOAQUIN COUNTY PUBLIC HEALTHSERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 M . <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'JZ <br /> (Complete In Triplicate) <br /> APLICATION 18 HEREBY MAGE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDgR INSTALL THE WOR(DESCRIBED. THIS APPUCATON 1E MADE W CtNeRj .WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1110.3 AND THE STANDARDS OF BAN"AWN COUNTY PVBLIC HEALTH SERVICES,Bervem owaiTAL HEALTH DIVISION. <br /> JOe ADDREBBroR APNP _� '') �)�[� /\ �;,`.; ,/ j.\�� CITY, LOT SIZE_ <br /> OWNER'S NAME.._I� z'54'74ti //L,.tL ADDRESS �PHONE <br /> CONTRACTOR PJ /L . /�-.��/% �-'l�i't ADDRESS Rol, <br /> O, YY /fi9W12Il2' me :2�7 PHONE 2, <br /> sue CONTRACTOR ADDRESS UCe PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAUDITIOM IF DESTRUCTION ❑ <br /> [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TFATNI I 1 HOW MANY <br /> bWeeae� <br /> INSTALLATION WILL SEINE: AESIDENCEV COMMERCIAL❑ OTHER❑ <br /> NUMBER OF WHO UNITS:/_ NVABEII OF SEDROOMS: NUMBER OF GROYEFJ: <br /> CHARACTER Of SOIL TOA DEPTH OF 3 FEET: APo6 e' PIT/SUMP SOIL CHARACTER: +� WATER TABLE DEPTH <br /> SEDgMEl TANKRFASE TP TYPEIMFO �-�GSI CAPACITY NO.COMPARTMENTS,TJ <br /> PILO TREATMENT MANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF PUMP BAND ON SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING UNE T}yT.�1 NO.E LENGTH Of LINES /"' r0-Vr/ DISTANCE TO NEAREST:WELL aJ0 yFOUNDATION�PROPERTY UNE <br /> FILTER BED LJ WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE \ 1� <br /> MOUNDED ❑MOTH LENGTHDEPTH DISTANCE TD NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAOE NTS /❑DEPTH_SIZE NUMBER DISTANCE TO NEAREST:WELL�FOUNOATOPROPERTY N PPERTY UNE <br /> SWFB .GI WIDTN�_IEHGTH��OFRITHONBTANCETO NEAREST:WELL_FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 HERBY 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 <br /> AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER ORUCENBED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFYTHAT NNTHE PERFORMANCE OF THEWORK FORWHICH <br /> THIS PERMIT IB ISSUED,I MALL HOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CA FC)AMA.- CONTRACTOR'S HIRINO OR / <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SMALL EMMOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWSOf�RNIA�✓4 �ANT MUST CALL 24 IOURe IN ADVANCE <br /> FOR ALL R�INSR <br /> CTIONS. COMPLETE DRAWING BELOW. <br /> BONED X / — DATE: <br /> MOT MAN(DRAW TO SCALE)SCALE_ -W � <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR PIOPOBED <br /> 2. OWUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DHIPOBAL SYSTEMS, <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURE., S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON a <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKSTHE PROPERTY OR ADJOINING PROPERTY. <br /> 1 <br /> a aW. <br /> I , f <br /> �L <br /> 3 Q.30.OL'D � <br /> PAWEN <br /> �r ;RIECEIVED <br /> SAN JOAQUIN GT.7UP11. �. <br /> _... i'USUC HEALTH SERVICE, <br /> -I`1`(IFiQNMENTAi.H I <br /> FOR DEPMTMENT USE ONLY DATE' AREA: <br /> APPLICATION ACCEPTED BY <br /> TANK,RT OR BUMP INS TIO BY DATE 1_1 FINAL INSPECTION BV DATE I l <br /> ADDITIONAL COMMENTS <br /> ACCOUNTINO ONLY: AID/ FAG <br /> PE CODE FfEINFO AMOUNT REMITTED )IEC ICASN RECEIVED BY DATE M/KNOT NMNBEi INVOICES <br /> i <br /> Pub.HeBKh Serv.-Enviro.174(3196) <br />