SU0000114 - Laserfiche WebLink

Home Browse Search

WAPPLICATION FOR LIQUID WASTE PERMIT JOAOUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION RO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 r FILEcop (209) 409.3420 'M L WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �•- (Complete In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OIL INSTALL THE WORK DESCRIBED. THIS APPLICATION 19 MADE IN COMPLIANCE WTTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. of(-090-02 \ H'—'S JOB ADDRESS/OR APN# Ib9'�_j 3flCnR BRAT - ROAb(APN nl I-I So-13 id IBJ CITY 911111�01 LAl>i LOT SIZE A(_ �S LAnI,C L_11<oF'.IyIA X2¢2 OWNFR'SNAME NIIyj';AN FAMILY -T-Rum AODREBS ► cAcS::), NoFZZ>a TNoR N'?ot,l Rc�AD PFIONE(ZCgJ��Q�' CAVIL- ."C'Alt'kEt17 0011 CALIt=ORNIA 95"L42 CONTRACTOR WA1e-TT--- R S. CJ91t ADDRESS I LIC#Cts IISS'Y' PIIONEL2(�)3E:R`41'>9 otzbIICp1L.1F'nRNIA V S4 O SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Z PA RCL•-S INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.) PE�«-o`'aTt(7*J PEtC TESTIO( I HOW MANY ` F'�RMt"(- Applloatlon s tM5 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 TANKIGREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKO TnEATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RTS ❑DFPTH SIZE NUMBER DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTI4 LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HERFRY 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 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 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 SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. CE SIGNED X �y-�✓<•'T�-LQJ TITLE: C I1/IL �NCaIh1E:E R DATE: E7• . �IvO PLOT PLAN IDRAW 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. J. OIMEN610NED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON C, INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY ...... ... ... .. .. . : ........� A71CSV-A Vvoon�ulo Rd An .... ........ . ........ .. ....... ... . .........'•.. ... � ..... I No's,Y,fil.L ;cA�-L I�. ....;UA��.:t�R P�Pc��Aer�>J Rte/-�q)�<-,�• ... ..:.. .. c - : .. : .. ... pAG?cr�(REMAINL11aQ-�Tc� IF.`1 JALCf)Y� 5 hs..Y:«r B1` LL��:141.SA�RiS . ... Jy ROAD 1z> pts V:E'TAIKF-b� >•3Yi .. .. .. .. .. .. .. .. 1 :....;_...:......;.. ..:.....:.............;............. . tJ�J ,c ASE .:............................. ..............:............ ?FURNI;P RQAD : .. .. _:... ...............i. .. .....:... ........i........ .. .. .. .. . � � i i .. .. E111� .. .. .... . ;.. .. . ... .:.. .. ...: . .. W:...... ............>..... ;.. ; ... .; 2.:.. .. 99:8 ......:....... ,... . . . . UA4UIN ..: :;....:............;............;..... ` SA,)V� rrQUNTY PIJf3CIC (IAGTN SERVICES !......... .... EWARCINMENIA FOR DEPARTMENT USE ONLY G APPLICATION ACCEPTED BV -��L.I�a �T � �i('�{'( DATE: Y �C AREA: TANK,PIT OR SUMP INSPECTION BY -DATE / / FINAL INSPECTION BY DATF ADDITIONAL COMMENTS: �' �'�• Q �/� i'._0, r ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO OUNT REMITTED HEC /CASH RECEIVED BY DATE $A/PERMIT NUMBER INVOICE 0