SU0004353 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT C, SAN JOAOUIN COUNTY PUBLIC HEALTH SERI r` [' j>� _ ENTAL , SION P.O. BOX 388, 445 N.ENVISAN MJOAQUIN IV ST, SLTH TOCIKTON, CA �Jn �} 2UT.BJB9 � l� (209) 468-3420 FAC # �_ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS EDI�V V tt I in Application is hereby made to the San Joaquin County for a�permutmtorre[ons tlruct and/or in V 18 made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. Job Address/or APN# Owner's Name �7� �j�/� �7 City-Y "r'� Lot Size //�7/"t 214 5- -.C,//%A )5-_Address,! // ii�-r i �� /iY/SL�Acn /��i Contractor_ � Address Lie# Phone Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION PERC TESTIel1 I How many (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEVER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Installation will serve: Residence_ CamN•rciel_ Other_ land Use Application f Number of Living unitam_ Number of bedrooms:_ Number of mrployeos: Character of soil to a depth of 3 feet: Pit/Sure Soil character: Water Tobin Depth SEPTIC TANKIOREASE TRAP 0 Type/Mfg Capacity No. Compartment• PKG TREATMENT PLANT ( 1 Distance to nearest: Well Foundation Property line pp,, LIFT STATION❑ Size_ Type of Pump Sand Oil Separa'or (enclosed system) T LEACHING LINE ❑ No. & length of lines Distance to Nearest: Well _ Founclation Property Line FILTER BED 11 Width_ Length_ Depth Wel( _ Foundation Property Line MOUNDED ❑ Width_ Length_ Depth " " Well__ Foundation Property Line SEEPAGE PITS ❑ Depth_ Size Number Well _ Foundation Property Line SUMPS [T Width_ Length_ Depth Well Foundation Property Line DISPOSAL PONDS ❑ Width_ Length_ Depth " " Well Foundation Property Line C 1 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 Sen Joaquin County. Home owner or licensed agent's signature certifies the following . 111 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such a manner aso to become subject to workman's compensation Laws of California." Contractor's hiring or subcontracting signature certifies the z following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensation Laws of California." The applicant most 24 ho n In advance or ail npuirad Inapeetiane. Complete drawing below. Signed %_z/ // �' i /7 ��' ,j� Title: Date: PLOT PLAN (Draw to Scale) Scale " to 1. Names of streets or roads nearest to or bonding the property. 4. Location of house sewage disposal system or 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property. and walks. G- �ll N Z r EI F UG 4 T STAN OA UIN ;UU o N ENT L HE LTH DNC. ON it LULCL711PLC'Tt'L� /.5-'�C��- FOR DEPARTMENT USE ONLY QVCTI:,QY 5 ZIJ L JD Application Accepted by n Date: Area _ B' Yks-f'��.,.t ccx tcou �w /su Tank, Pit or Scarp Inspection byDate / / Final Inspection by e c Date f�./-5t/{- e-,fr-e 4 c 7r Additional Comments: " gj `x fi.reSmk'-�o�/"os� Y �•rfa-u-✓z,--� STC ACCOUNTING ONLY: AID# FAC# PE1CODE FEE INFO AMOUNT REMITTED CHEC (CASH RECEIVED BY DATE SRI PERMIT NUMBER INVOICE l 0 I _ F __._