SU0004580 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT SscN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED IComplBb in TrplioatA) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111^0.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNI_� �' 1 1� \ �il[J � 1<1I c�CT,' _1'11�1Rt�.J 1 '� LOT OWNER'S NAME J /(�� 1 �C'-�l\7 , ADDRESS 'Y'�ZQ !' \'1 t 4'T-1-4 tfT,3 vlr Y 14-)1- PHONE 7i5'1, CONTRACTOR�._�p `�r�n.-f lt'_ ADDRESS 1'1'K�-j <'.l�-+� 'i ��/r�l UC,I �C?"Il-1 PHONE L-35, SUB CONTRACTOR ADDRESS UCY PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION Q- REPAIR/ADDITION ® DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)1 I HOW MANY Appllmtlon INSTALLATION WILL SERVE: RESIDENCE a COMMERCIAL ❑ OTHER ❑ r NUMBER OF LIVING UNIT& NUMBER/OF BEDROOMM&: 3 NUMBER OF EMMOYEES: l CHARACTER OF SOIL TO A DEPTH CJOFFn33P FEET: C NkM (IPI-f- CA PR/SUMP SOIL CHARACTER: no LT)p_F^ WATER TABU DEPTH AP O'O ' SEPTIC TANK/GREASE TR" (�F7'Y' i�L L-fr CAPACITY / UG NO.COMPARTMENTS �� ;. WO TREATMENT PLANT❑ DISTANCE TO NEARFlT: WELL FOUNDATION % (7 PROPERTY LINE � UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) .. LEACHING LINE 14 NO.A LENGTH OF LINES CLl x !4 Q I DISTANCETO NEAREST:WELL lf• J FOUNDATION �!Y, PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RTS R DEPTH :Dt� SIZE 3->(, LL NUMBER _DISTANCE TO NEAREST:WE '61` FOUNDATION ^C'f PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 11 DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY 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 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 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 WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIO WS OF CALIF/(�K({�/�N�IW- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPUTE DRAWING BELOW, SIGNED ��YI / 1 1V/ TITLE:�Ji -h l�,l7 - (--, DIC_ �- DATE: PLOT RAN(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 PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. 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. c- Y1 M ....... P4lflVhE11T 2 1995 II