Laserfiche WebLink
I <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br />{ <br /> --------------------------------------------------------- (Complete in Triplicate) Permit No.--L_ _���._! <br /> ------------------ ---------------- --------------- <br /> Date Issued-773--2-6-. <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-insia e-workherein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing R.u'les and Reguiations: J <br /> i - - ------- ---- CENSUS TRACT ---------- <br /> JOB <br /> ' <br /> JOB ADDRESS/LOCATION ._' ! ' .. G ._ . = Phone <br /> Owner's Name -=------- ' <br /> Address- - <br /> --- -- ---- City � �`�--------------------------ziP � <br /> _ - . _''S <br /> Contractor s Name._ �u 4�---1rTG/�. --------- -------------- <br /> Contract( License # --- - c�'._ Phone'O" = -- <br /> Installation Twill se-v}: Residence . Apartment House,❑ Commercial ❑ Trailer Court ❑ e <br /> P <br /> i � ....�.. . � �.. .. Motel Other------------- <br /> F <br /> Number of living units______ __________Number of be �_-.__-Garbage Grinder•____---___,Lot Size.---.-- j-,.r --- .--.--.----------- >----_--_.__ <br /> Water Supply: Public System and name ` : ----- - . .'- -------------=---------=- _-,-_ - -._ Private <br /> PP Y , r <br /> Hardpan ❑ Ado ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam Clay Loam <br /> r -------------------- <br /> Character-.of soli to a depth of 3 feet: ' Sandbe,0 Fill Material------------ yes, type_`;_._._____---------!� --'t----f t <br /> f <br /> F, (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 fees} <br /> „N ------ <br /> ---------- <br /> nue <br /> 'Liquid Dei <br /> th.'-- --------------- <br /> E PACKAGE TREATMENT . SEPTIC TANK I l Size-----------------------------------------------------=--- - r►en#sType Material - ' TNo CompartCa aCitY- =--- =--- ------- ----=- ---- ------ - •~ <br /> Distonce`.to nearest:.Wel.l___.__-- __---- --- <br /> --_--Foundation. __:::.___ ._ _Pro 1 Line. <br /> ` LEACHING LINE [ l. . No..of Lynes---------.---------- ----,---.Len gth of,each li.na�------ i--.--]-----Total Length.'-------------------,---------------- <br /> \ .. <br /> i D Box--N..___-...Type Filter Material._--------_ De th Filter Mater�c�L_ ---- ----- ----- ----------------------------- <br /> q _.. <br /> I P <br /> Distance to nearest: Well__ ='r'•Foun tion - _--_ -.-Property Line __ ._ <br /> - O[ 1 e — <br /> - ' t : i ti 3 <br /> .-- .����r i "01-1 <br /> k,F let- Yes ❑ No ❑ <br /> SEEPAGE PIT [ ] De th.___a."--.---Dia'meter--------- -- -----Number------:----------'--?------'----' <br /> - P, mss,_ � <br /> # Water Table Depth' ---- ------------------------ -- Rock Size-------------------------------- ------------ <br /> n-4 <br /> ------- <br /> ` Foundation - r� r cam_:_ Pro fine_.___. __ _. <br /> Distance to nearest. Well _---" :--_-• ------ Vic' p: <br /> REP R/ DDITION- ev. Sanitation-Permit#---. _____. --:-:---------- �.bafi ----- ------ <br /> �._ P )j <br /> Septic Tankt(Specify Requirements)-------------------- +4 �+ ----- . .. "'�,, <br /> I .' .Y� I" Gv 1.� ' ------ -------- <br /> Disposal Fuld (Specify Requirements}-_ ___ c � _--_--_r J ___ <br /> I <br /> { r J <br /> ` -------- -------------=-------------------------- _ ___ ___ . . - - --__ _ ---------------------------- <br /> ------ <br /> e <br /> ----------------------- <br /> - -.- I i. - <br /> --------------------- <br /> (Draw <br /> ----------- --- / -.�� ` <br /> " (Draw existing and-require a ition on4everse side <br /> r [ (i'_ . <br /> h work will-be done-in accordance with San Joaquin County <br /> hereby certify that I have prepared this application-and that t e , <br /> Ordinances,' State. Laws, and Rules and Regulations oPthe: San Joaquin Local Health Distrrict.!Home owner or licensed. agents <br /> signature certifies the following' <br /> lI 4 <br /> "I certify that-in the erformarice of-the work for hich this permit is Issued, 1 shall not'employ)any person in such manner as <br /> w <br /> to become sublet o ork' s .Co pensatio++ laws of California."{ ! ,P�-,3 # <br /> Signed----------- ems. --- --------------------- -- - -- ------------ ------ <br /> I . ... 4 <br /> 4 F <br /> �. - <br /> _ 'Owner <br /> -Title---------- -------------- ----- - -------- , <br /> �Y -------------- --------------------------. _; .. ) <br /> ...(If other than owner] _ i <br /> FOR.DEPARTMENT USE ONLY * t ) ' <br /> APPLICATION ACCEPTED BY_______________ - <br /> .� <br /> ------- ------------ ---- ----------------------------- <br /> DATE.: - <br /> DIVISIONOF LAND NUMBER -- ---------- ----- ---- ---------- ----------- ------------=---- ------------------------ ---::- :-.DATE- ---------- ---=-- --------------------------- <br /> ADDITIONALCOMMENTS------ ----------------- - --------------------------------------------------------- --------------------- ------- <br /> r - <br /> ------------------ -------------- ---- ------------- ----------------- ----- --,--- ---------- -------------.------------- .-------------------- ----------------------------------- <br /> T <br /> -- ------ ----: ------ <br /> ------ <br /> - ----------------------- - Date <br /> Final Inspection b _ w_ ,: �� _ ... M _ _r --- - .- --- P-- <br /> ----- -- -- -- - ------------ ------- --- <br /> b <br /> PY ------------------------------ ----- <br /> u F&S 21677 REV. 3M <br /> ► <br /> EH i3 2a SAN�JOAQUIN LOCAL HEALTH DISTRICT <br />