Laserfiche WebLink
FOR OFFICE USE: <br /> _. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------- ----------------- ---- � .7 6 <br /> -�-- -------� _ (Complete in Triplicate} Permit No. <br /> --------------------------------------------------------- <br /> 1 Date issued__i <br /> --------- --------_--_---_-- ------------------- This Permit Expires 1 Year Fram 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_ <br /> ------._ .--- CENSUS..TRACT------'------------------------- <br /> r <br /> Owner's Name � ✓ = --------- --------- Ph <br /> .- - <br /> Phone- _-_ __ <br /> Address ` - � -r�� City ✓ _ P <br /> Zi <br /> t. . _ ZV - --.License #.__3z�z 2 - Phione-------------------------- <br /> Contractors Name-- - --- --------------- - + <br /> Installation will serve: ' Residence A artme'nt House Commercial :Trailer Court l <br /> Motel ❑ =---- = ._ - + <br /> Other <br /> ' Number of bedrooms...__ Garba e.Grinder------------Lot.Size----._` --- _--- --.._ _-.____ _._.. <br /> k <br /> Number-of living units:--:__ y <br /> - g <br /> Water Supply: Public System and name__________ ___________________--:-, - ---- -- -- - Private ❑ <br /> Character of soil to a depth of 3 feet: ; Sand ❑ Silt ❑ Clay.❑ p Peat ❑ Sandy Loam Clay Loam ❑ <br /> Hardpan E] Adobe r Fill Material_..-.____.__If yes, type----------------------------`--- <br /> (Plot plan, showing size of lot, location of system in relation to wel]sbuildings,.etc.:must be placed'on reverse side.) <br /> - <br /> % <br /> NEW INSTALLATION:" :(No' septic tank or s". dgeepe'.pif permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [11 Size"_ - `------ ------- Liquid Depth-- 4 <br /> 1 1 P <br /> € Capacity------'--=-- ------"Type------------ ------ MoteriaE- Na. Com artments. I---. ---T---j- --Pr� <br /> .'Distance-to nearest:.Well. -=--=-------------------------------- -Foundation _._._'__. - op. Line <br /> LEACHING LINE.. .[] No, of Lines__._-_„_--_--,',-,_.:-----,.teng'th of each-line.--__,. _______------______Total Length.,-_•__ ---------------------------------- <br /> -------------------------- <br /> 'D' <br /> _- _-- __.__-________ <br /> 1 'D' Box----..___?--Type Filter Material ___Depth Filter Material__ -------------------------------- <br /> Distance <br /> ----- -- - ------------- ------ ---------------- <br /> - <br /> Distance•to nearest: Well __: _--_-Foundation._ ___---_ ___--_Property Line------------------------- <br /> ------- <br /> ---- -- ----------- ------- <br /> SEEPAGE PIT [ ] Depth________________Diameter- ____--._.- -__--Number Rack Fi!{ed , Yes ❑ Noy <br /> . y. 3 <br /> } Water Table=Depth------------------------------------------- Rock Size- ---- -------=----- <br /> - ----Foundation----- ------ -,-- Pro Line- ---- ----- <br /> Distance to nearest: WeIL..__.__.._______--------------------- ---- P• <br /> --.Date--------------- <br /> REPAIR/ADDITION (Prev, Sanitation-Permit#._�-.�--�--'--:`----=-----------------,-------------'---- ---------------------- <br /> Septic <br /> -- --Septic Tank'(Specify Requirements)------------=--- - = = = - <br /> ! Field (Specify-Requirements) ----------------------- ------'---------------------------------------.----- - <br /> 6 <br /> Disposal -----------------.----------------------- ---- - --- --------------------------- ---------- - <br /> � -------- <br /> 14 <br /> - - <br /> a <br /> „ .. <br /> [ =---- --------------------------------------------------- ----------------- <br /> (Dr( istin and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work-will be done in ciccordance 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 the following: q l <br /> w <br /> "I certify that in the performance of ahe°work for which this permit is issued, -1 shall not employ any person in such manner ras <br /> to become subject to Workman's Compensation laws of California.” <br /> Signed------------------ - - _ ----- w" V <br /> ------ <br /> r� --- 4 <br /> Y-�------------- -------- ---- - --------- -- ---- ---- � - ------------- Title- -- /t-r . <br /> (if other than owner) t <br /> t FOR DEPARTMENT USE ONLY- <br /> ' <br /> I APPLICATION ACCEPTED BY - d.r - --------- DATE...' -- --------- <br /> DIVISION OF LAND NUM IBER:-------------------------------- ----- DATE.------- --------------- = ' <br /> ADDITIONALCOMMENTS----- --------------------- --------------------- ----- ------------- -------------- -----------; <br /> E _ r ..__ .. - - <br /> -----------------------.____ .- ____ ___ ___-----------------------------.______. <br /> f <br /> . <br /> q ____-_______________________________________ _/ _-_._--_--.-__-_-----.__--.------------_---______.___-----__�-----______---- _____. �__.__ � ___..____.._________.� <br /> Final-Inspection b --� . _ - te_ -%/ <br /> Da <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M <br /> F� <br />