Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION .FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No./ 4 <br /> --------------------------------------------------------- <br /> Date Issued_/_l_=/j4�_-_2F' <br />_ _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing.Rules-and Regulations: <br /> JOB ADDRESS/LOCATION- --_.:-- - --` ___: ::.__.,._ ------------ ---------------------------- CENSUS vTRACT. =------=------------------ <br /> Owner's Name-------------- --------------`-------------'------ ------------- -- `-- ------------------------------ -------------------Phone------- -------- ---------- <br /> Addre's - 7 r- ------ City - e ?VLO -----zip <br /> icense #_32,Fcl�'f_--_--Phone.- �'7-___�lr fa_. <br /> Contractors Name :C� �. ' ? lI+� --=------=----- -t' . <br /> Installation will` serve- # ] Residence( Apartment House.❑ Commercial ❑ Trailer Court ❑ , i <br /> S Motel-❑ =Other------ ==--=------- ----- --------------- <br /> Nu'mbee of living units;--_`'_/s_-____'Number of bedrooms .___Garbage Grinder ------ -Lot Size--- Vic_Y`_r _______________ <br /> r <br /> Water Supply: Public System sand name--- --------- ---` ---------- - --------------- ---------------------------------------------- ------------------------------Private <br /> � r <br /> Character of soil to a depth of 3 feet: Sand Silt❑ +Clay ❑ Peat Q Sandy Loam ❑ Clay Loam ❑ <br /> i <br /> Hardpan [] 7 Adobe❑ Fill Material------------lf yes, type---------------=---------- t <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: '(No septic tank or seepage :pit permitted if'public sewer is available within 200_ feet,] <br /> " / ✓ <br /> Size TAN � 'Matefrial___ - Liquid ePACKAGE TREATMENT pth-'- -- ----- ---� <br /> Com artments_.a._'::.----`------------ <br /> 'Distn__-_/ Prop.-Line-7 ------- ' <br /> LEACHING LINE [ ] Na. of Lines-' <br /> __ _________ __________Length oof ea� lin ___- �_-_----- ------Total Length ___ �____________-----________-__ <br /> . ;D' Box.../-_-_...Type Filter Material_�'__2_____.___Depth Filter-Material__ :✓___'�_!__.____�-L_�_______________________�_ <br /> ? Distance'to nearest: Well-`_1_ _L3_'_ f____-Foundation___ ___C1- ___3-..Property Line---- __' __ _..___t [ <br /> __Number______________________.'_ ? Rock Filled Yes No <br /> SEEPAGE PET [ ] Depth________________Diameter.�.____.:_._.____ ❑ E l <br /> f Water Table:Depth. Rock Size ----------------------------------------- -s <br /> Distarice'to nearest: Well----------------------------------------------Foundation---------_----------------Prop. Line--------------------------- <br /> REPAIR/ADDITION <br /> - ------ -----REPAIR/ADDITION (Prev, Sanitation Permit#-------------------------------------------------------Date-------------_-------------------------__----_} <br /> Septic Tank (Specify. Requirements)------ -- -I------------- ---------------------------------------I------------- ------- -- <br /> Disposal Field (Specify,Requirements)--. ._- --- ------------------------------- = <br /> ------------------------------------------ ----------------- ---------------------------- ----- -- -------------- -- --- ----- --- -- -------------- --------------------- <br /> - ----- ----- - ------ <br /> ----- ---- ----- <br /> -----------_-------------- -------------------------_------.------------_----------------------------------------------------------------------------------------------------------------------___- <br /> (Draw existing pnd required addition on reverse side] <br /> I he: certify that I have.prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws; and Rules and Regulations of,the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies th, following: <br /> "I certify that in 'the performance of.the work for which-this permit.is issued, I shall not employ any person in such manner'as 4 <br /> to becomes le t to Workman's Compensation laws.of California.". . <br /> Signed--------�- - ------ - - -- - --- - � <br /> ---=------------ <br /> --------------- ---- - ---- Owner <br /> J ..�'- ---------------=--- --------- - Title <br /> BYE -- - -RA <br /> (If other than owner) <br /> FOR DEPARTM E ONLY <br /> APPLICATION ACCEPTED. BY------- . f __ _-.. '" =DATE _. .1 --- --- <br /> DIVISION OF LAND NUMBER--- =------ ------- --- ----- -- -- -- -- _--- ---------.DATE--- ---- ----------------- ----------- -]-- � <br /> ADDITIONALCOMMENTS-----=------ ------------- ---- ----------------`---------------------------------------- ---------------------------=------------------------------------------ <br /> . w <br /> ------------------- -- ----------- ---------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- <br /> --------------------------=------------------------------------------ - -----------------------------------------------------=---------- --------------- ------------- ----------------------- --- <br /> ------=----------------------------------- --------- ---------- -----------------------------------------------=--------- --ya <br /> Final Inspection by..- -__ •- t- _//-2- <br /> --- _ -------- - - - --- Date <br /> EH 13 24 --,SAN JOAQUIN L CAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M t <br />