Laserfiche WebLink
APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQWN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.0389 <br /> (266)468-3420 <br /> NON-REFUNDARE P AEXPIRES 1 YE4R FROISSUED v� <br /> ICampk u in Trplint.) <br /> N'PUCAiION IS HEREBY MADE TO THE SAN JOACUIN COUNTY FOR A PERM17 TO CONsMAUCT A WGA INSTALL THC llW DESCRIBED. THIS APPLICATION is MADE IN COMpUANCE'.NTH Bµ <br /> JOAOUNI COUNTY DEVELOPMENT TRUE,CHAPTER 9-111 0,3 AND THE �DAEOS RIF SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES,FNVIEION!¢NTAL HEALTH Df"aaN. <br /> Joe ADORESS,OR AIPrwt• Lp:BrzE�O Lc,fQ-�l <br /> OWNER'S NATE W • `D l' ADDRESS ! 2 <br /> PHDIg 9� y�2o <br /> CONPRACTOR� A3 t,j t 1 'e ADDRESS 3 / <br /> SUB CONTRACTOR` PANE <br /> TYPE Of SLYRO WORK NEW NSTAIL,LTION❑ IND'AWADd TION DESTII IcmN❑ <br /> IRO SEPTIC SYSTEM P9"TTEO F PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET Of BUILDING.) PERC TEST(.11 1 NOW MANY <br /> M <br /> INSTALLATION WILL SOME REl <br /> SIDENCE U COMMERCIAL❑ OTHER❑ <br /> NUMBER OF LIVING LNNTS:�NU11B81 OF BEDRgOIM:�_NLIMBOL OF EMPLOYEES; <br /> CHARACTER OF SOIL TO A DEPTH OF O FLET: IJ PrTtSUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SIPM TANEJGFEASS Tkt ❑TYHIMFC �ADNe1��-CAPACTv�._(p OOI T NO.COMpAII'fN(liT.BI r ^XSIS� <br /> N1(O TIQItlNEJ1T PLANT❑ dGfANCE TO NL'.VIEST: WELL� ` FOUNDATION J � {pDPERTY LINE <br /> UFT STATION❑ TYPE OF PUMP-- SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> (�J I ! <br /> LFACHMO UNE NO.A LENGTH OF LINES. DISTANCE TO NEAREST:WELL/40.46"FOUNDATION rya PIROPFMY UNE <br /> FILTER BED ❑WNFTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST;WALL FOUNDATION PROPERTY LINE <br /> SEEPAGE PRA CI DEPTH SIZE_ NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SWC' ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> OW-OSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL_FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATON AND THAT THE WON(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND Pk1LE8 <br /> AND REGULATIONS OF THE SAN JOAQUIN GOUNTY,HOME OWNER OR LICENSED AGENT'S INGNATLI E CERTIFIES THE FOLLOW HO:'I CERTIFY THAT INRHE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I&HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO Y.OWMANB COMPENSATION LAWS OF CAUFOEWIA- CONTRACTOR'S HIRING OR <br /> SUB{:ONTRACTNG SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 IFORN A` PERSONS SUBJEDT TO <br /> WORKMAN'S CQO�MNS"ATON LAWS OF CALIFORNIA.' TI A7KJCANT MUST CALL M gOIM IN ADVANCE FOR ALL HEOUIIIEL INSPBC710NS.COMPLETE ALLOFLA"M6 BELOW. <br /> /7 L <br /> SIGNED% • TTTLE:_ DATE: <br /> PLOT PLAN(DRAW TO SCALE)SCALE.-m <br /> I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1,LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORM DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> O.DIMENSIONED OUTLINES AND LOCATION OF ALL EXMTINO ANO PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FNTY FT.ON <br /> n LUDING COVERED AREAS SUCH AS PATIOS,DRVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PRDiIXTY. <br /> f II I oA <br /> t <br /> L <br /> • .... <br /> ...AUG.7 250 <br /> t <br /> ..:.......i.. ...... ...... <br /> : -. ....... <br /> a� :• �� <br /> v <br /> • <br /> �. <br /> . . <br /> t76 <br /> (}. <br /> , <br /> pQ,Y.: v. �,..............•....._. . „3.. b........... ........: ti <br /> ... .......may .. <br /> PIP I <br /> V"r <br /> S 1j <br /> SAry''�FQLlj1iSES+,�rvtl3u'�N .... .. <br /> ti FOR 0 ARTMIDST USS ONLY fix] <br /> DATE: `-'� O ASFA: <br /> APPUCATION ACCEPTED BY �F MEO4 /T <br /> TANK,PIT OR SUMP INSPLCTON �/ DA7CG l ! �fMIAL INS ON BY <br /> ADDITIONAL COM ^fe: <br /> ACCOUNTING ONLY: AIDN FACR <br /> PE COOc FEE INFO AMOUNT RA1 NEC” ASN RECEIWED BY DATE SYI !..as <br /> 0 1 Y5►2 Oa X70 <br />