SU0002230 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 SFS-o 1: (209) 468-3420 ' NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED q'N (Complete in Triplicate) ;- APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION 18 MADE IN COMPLIANCE WITH E JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARD@ OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES.ENV( NMENTAL'HEALT? VISV0 ..- l`173 ��/�T %r �' CITY `)Ltol- t� 4 1 02M�4,✓ JOB ADDRE66/OR APNI /'✓�-� �J r"- OT'/812`Ex� V OWNER'S NAME �1 T�LS I 5 ADDRESS ��7 3 V," / ✓ F A,- PHONE CONTRACTOR ADDRESS LIC( PHONE SUB CONTRACTOR ADDRESS LIC' PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW I 1 HOW MANY Appli adon 7 INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: U /V'C/(� RT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEP'TIC TANK/GREASE TRAP ❑TYPE/MFG r�C I �j T/ ✓7!� CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE NO.8 LENGTH OF ONES �."� DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STAT E LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUaJECT TO WORKMAN'S COMPENSATION LAWS OF[CAUFORNIA.' THE APPLIIC..AANNT�T MUST CALL 24 HOURS IN ADVANCE FOR ALLREE�QUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: (LLf-_•-�?'P/� DATE: / C PLOT PLAN(DRAW TO SCALE)SCALE_ 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 OUTUNES 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. _ INSPECTED..B;UT NOT. . . . . . S1�NED . ...........:......:......... .._ ...... .... ......... . . . .. ....................:.......:......... .... ........... .:....... ... ...: ... ......... .. . . . . ............: ... .,..:...................................................................: ... . .. . ............................... ............................................. .. .. .. .. .. .. ..:............................. .. ...................................................:.................... ;...........'......'....... .. .. ..'....... . .. ....................................... .. .. ....... .. . F . R . .:... . . .. JAN 4'2000 ....... . Iur1 T PUBUC NATHSEFVICL ,n FNVIRONMETANFAISM DIVI SIi lI. l _ ��//�s,,' FOR DEPAPTMENT USE ONLY APPLICATION ACCEPTED BY AiP--/J�iN�i v lL: n DATE: / / O v AREA: U �/� TANK,PIT OR SUMP INSPECTION BYl�n M 1/ /] DATE /'/ / FINAL INSPECTION BY n,. DATE / � " ADDITIONAL COMMENTS: C-�U�� /I KIK !7-! �yI e �r "c�-f` ';;�±vim' ACCOUNTING ONLY: AID' FACR PE CODE FEE INFO AMOUNT REIJIIITED IEC ASH REC VED BY DATE aR/PERMIT NUMBER INVOICE I �aw rw ' `� D� 2,LL6 7 �I Pub.Health Serv.-Enviro.174(3/96)