SU0001001 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR LIQUID WASTE PERMIT v SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ATTACHMENT A ENVIRONMENTAL HEALTH DIVISION •� P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripikata) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI ra v V Tl1AT�yt /PU - (A9 PN op6l/3301 (�.O/�I `�] � LOT /SIZE (��7�r�L, OWNER'S NAME�Q-U I� J�tMR p ADDRESS /�I 7 �/4n N. V1nz--s�Q - �C-/ • 'PHONE-36 d / C! CONTRACTOR Jim arr�S MMt�JMDDRE88///I//�I�r FJ.s 'x „�2G r/}li�� S PHONE / BUB CONTRACTOR ADDRESS —UC71tT Qa R PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPABVADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.) PE RC TEST(s)I IIHOWW MANY AppNoeeon/M-5 a—a INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPEIMFG CAPACrrY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OII,SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.i LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS [I MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATION 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 SUE ,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A6 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBLONT ING S NATURE CERTIFI HE LOWING:'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUC,)ECT TO WORKM COMPE SATION LAWS C FO IA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPILE DRAWING BELOW. SIGN X a�>f� ' TITLE: O�I�'� DATE: PLOT PLAN(DRAW TO SCALE)SCALE 'to T, 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. EXPAIjS10N OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. 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. ..._------_-----_..,... n A MEN,1-11 RFCr. F JUL 19 9 SAN JOAQUIN COU\. y ENVIRUBLIC HEALTH SER CES C. BROWN M. HIES /� D. CAFALDO t 601Y L HEALTH DIVISION 10, (00 —20 E115T/NG /0' TENNECO 134/- PIPELINE EASEMENT 00 11 Q� SEE PARCEL 1 S' I to DETAIL 13.85 ACRES SHIMOZAKI h METTLER I 1 AI I PARCF1- K 12.8/ ACRES (� SEE o zoo IES �I? Df TAIL yyi �I I 1341' B. JON5501Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY <(� DATE: `} ( AREA: TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE / / ADDITIONAL COMMENTS: ACCOUNTING ONLY: A1D+r FACN PE CODE FEE INFO AMOUNT REMITTED f, CHECKfldAM RECEIVED BY DATE an I PERMIT NUMBER INVOICE• Z.