SU0000948 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT A'JOAOUIN COUNTY PUBLIC HEALTH SERVICES' FILE C ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95 I-M (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplkats) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFIK DESCRIBED. TH19 APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEE- �IvR�V`ICEB,ENAP40NMENTAL HEALTH DIVISION. JOB ADDRESS/OR��A))P�Na2 )S�C) � 1••S YY�� Ck) W rnL.11r-\ ►L.�]CY S l VG� LOT SIZE"i QUt-- _ OWNER'S NAME_ IL.J.�\)�i LT\V J ADDRE88• , ,S O o W. y/ 'J ulR� 2p _ PHONE CONTRACTOR QuN hlecui Or AsscI ADOnEss ?A'0 Sub '?LA �, LICE PHONE 2ZZ c� 7 SUB CONTRACTORMLL� AL '- w I ASSn�ADDRESS (,�L ycu'Sl ibkj AMC LICE� 44u1 �. PION Z�l J - O I TYPE OF SEPTIC WORK: NEW INSTALLAI IO NAp� REPAIR/ADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) FERC TESTUI( i HOW MANY V APdloatlon• m 5- 17--"LC L INSTALLATION WILL SERVE: RESIDENCEAD"'COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF BOIL TO A DEPTH OF 3 FEET: FIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/ORFASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.A LENGTH OF LINER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED 11 WIDTH. LENOTIl DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAOE R78 ❑DEPTH 912E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNF SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,ANO RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM TI LAWS OF UrA?Rfl1A.• THE APPUCANT MUST CALL 24 HOURS IN ADVANCE POR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING SELO a'" — �'�w"c17i► 5+:_~? s�+ �a �''L'�'1��UCf11U(c�'if li C� C 81 D X - DATE: f PLOT PLAN(DRAW TO SCALE)SCALE Ip 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. (49 , WILH0IT-DOUGLASS TRIM , vm 6 � I s „- Sen•...• I AM p • �.:;' WILHOIT-000GLAS TRACT ••••; �P EP. 4 e, �• - eti„ e- - —,• _ .. 998 Skil /EJ.4(?trlN PUEju GUUNT� ». A• °• ENYIRO G FrEACTIi sERVI �c rr r rnvg FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By DATE: AREA: r 1 TANK,PT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: Ct,.I—Q 12:;-OA Q, Y '/ S ACCOUNTING ONLY: AIDE — FACE K r ' 14 ^ 7k///��, .7 PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE SA/PERMIT NUMBER INVOICE 0