SU0002607 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT S eA JOAQUIN COUNTY PUBLIC HEALTH _ AVICES _ ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TTiplintE) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOR INSTALL THE WORK DEBCRBEO. THIS APPLICATION IS MAGE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPNFNT TOLE, � OCHAPTER//.e-1-110. ADA F/BL'ALJ'AOUINTYMOW:HEALTH BER EB. VIRON �HEALEALTH DIVSION. JOS ADDREBB/OR AM' C /j/i COY ` 1--�y,�LOT WE OWNER'S NAME ADDRESS 1(,.��//nMIORE (�'� CONTRACTOR �� ADDRESS ? Z me iLY_L(a�ae PHONE �� '�/ BUB CONTRACTOR ADDRESS LIC/ J� HONE TYPE OF I EPTIC WORN: NEW INSTALLATION ❑ REPAIMADDITION ❑ DF/TRUCTION ❑ Y�Y Z IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 300 FEET OF BUILLNNG.1 P91C TUTIFi 1 1, iLA ApPYatlen! T(1� INETALUIEION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ / NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: /( G CHARACTER OF BOIL TO A DEPTH OF J FEET: PFT/BUMP SOIL CHARACTER: WATER TABLE DEPTH l ✓ �� L/d�� tFITC TANR/OIEASF TRAP ❑TYPE/MFO CARACT' NO.COMPAREMENTB JCI PILO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF MMP BAND OIL SEPARATOR IENCLOSED SYSTEM? LEACNNO UNE ❑ NO.S LENGTH OF UNER 018TMCE TO NEAREST:WELL MUNOATION PROPERTY UNE FILTER SED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION MOPERTV UNE MOUNDED ❑WIDTH LEMTN DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RT; ❑OEM" m2E NUMBER DISTANCE TO NEAREST:WELLMUNUATION PROPERTY UNE BUMP; ❑W'IDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE GONE IN ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES AND STATE LAWS,AND RULER AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORUCENBM AGENT'S SIGNATURE CERTIFIED THE FOLLOWING:-I CERTIFY THAT INTHE PEPEOEMANCE OF THE WOR(FOR WHICH THIS PERMIT 08 ISSUED.I SHALL NOT EMMOY ANY PERSON M SUCH A MANNER AS TO BECOME SLI TO WOIKMAN'9 COMPENSATION LAWS OF CAUFOEMA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIONATV RTIFIES THE FOLLO NG:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO MNNFMAN'B COMPENBATIO /� DOFF CAJM A.' THE AP,MIICARTT MUST CALL. HOURS IN ADVANCE FOR ALL REOURED INSPECTIONS. COM DRAMNO BELOW. BONED% 19�L1 wF" TOLE: DATE: O PLOT PLAN DRAW TO SCALE)SCALE_ -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P OMSED }. OUTLINE OF THE FROPERTY.WITH GWENWONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RAORID OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AKAR SUICH AS PATIOS.OR IEWAYB.AND WALXS. THE PROPERTY OR ADJOINING PROPERTY. rq s / 8 : �PuI lc�tn too/, MtAYretci4 i SEP 10199,8 rU(3LL^,GAOL NVIHDAP H 4LTH SEgVICES 'SEN rqL NEApIk;-1 2 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY /I/ / DATE: D may/ AKA.�I TANK,PR OR BVMP mBPECT/IOIi/BV DATE I I FINAL INSPECMN BBBB��Y N`f /�Orl TE ADUTIONALCOMMENTS: Y/ .y /10/1 G .- I/ I '` ACCOUNDHO ONLY: TITTI ADE F _ FACI Y PE CODE FEE INFOAMOUNTREMIIEEO CIIECIU ASH RIM FNFD BY DATE ;R/FRPLIT NU.MSER INVOICE• C11 0 q Pub.Health SeN -EnArC. 174(3/96)