SU0000948 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT .T--&JOASUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PCOMpltyj AF"ICAT10NIS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO COCNSTRUC•I NO/ORI INSTALL THE WORK DESCRIBED. THIS A ION DERH BAN JOAQUIN COUNTY DEVELOPMENT�TI(TLE•CHAPTER 9-11 10.$AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AFNJI » lJ0 �) MU L�-L" 2 2� �SO� IT 1U�c�YL CN-Y._ `, � �7 y�^ -23'S60 [� �` T� LOT SIZE f n k(L OWNER'S NAMES(^�1�-•� �"` „ \V5S ADDRESS W. 1`,LJv"i1L, �1 'S 1 L/Cp Q PLIONE Z-- 1 CONTRACTOR ` tjI\ A A %ajf1 ;S( �L,AQC, LICI // f\\ C 9 1� ,A n!,` L� PHONEIZ.G Il Z..3 I ��-lOS' SUR CONTRACTOR i:il_ U_f\N/\Er�.So/U I uc. \�.ArK. 414 ( 61 PHONEI'L(;<I,�b 1'31b( TYPE OF SEPTIC WORK: NEW INSTALLATION REPAMIADDITION ❑ DESTRUCTION ❑ [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) P9tC TEBTI.I( i NOW MANY App{Io�tlon 1 - w Z - Zoz INSTALLATION WILL LEAVE: RESIDENCA-f7-- COMMERCIAL ❑ OTHER ❑ ►iNS' NUMBFR OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEE/: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPEwra 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 LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY SINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS 11 MDT" LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WOFW FOA WHICH THIS PERMIT 15 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR-$HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF C ALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. - A^ ( GAJ h y/ SIGNED X' r/ Il G - `(.�1/ TITLE: S�A/ I GAJ 1 ty ce DATE: I v /S As PLOT PLAN(DRAW TO SCALE)SCALE •to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR FNIOPOSFD 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED STRUCTURES, EXPANSION SEWAGE DISPOSAL SYSTEMS. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OFF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON THE PROPERTY OR ADJOINING PROPERTY, .. hi WILNOiT-DOUGLASSb•+�P'�T,akE101�r-a .eM lY.OCT �0 5199$)ON C`in.iNir :rt i 's ": ,�N'1..0f!.�.;L7t4i ' 3 .........._ I M1:NTAL HFALI 4 , ,._. «' .... a e..y i);� .... ;, WILNOIT-DOUGLAS TRACT I , ��- � — ——_.—- 1 w n•ourn caw.r .'.. � ••.•. xtttf•an xwr + � .... ..........:............................:..............:...... -y() FO EPARTMENT USE ONLY APPLICATION ACCEPTED BY '�'v J ��/�''y�� DATE: AREA: 2- I 7 TANK,FIT OR RUMP INSPECTION BY DATE / / FINAL INSPECTION BY iL —� �r. DATE / ADDITIONAL COMMENTS! AswV'"�•�t�`•" I ACCOUNTING ONLY: AID/ FAQ# PE CODE FEE INFO AMOUNT REMITTED CHECK/)CASH RECEIVED BY DATE SR/PERMIT NLN ISIMv a :l'1 !INVOICE