79-181 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- -------------------------------------------------=- Permit No--- ��-- (Complete in Tripli ate Date Issued___^ 7 ! This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit o construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION------------------ ------ --`----- QZ---- ------_----------+ T ----------------------------------------- ------------CENSUS TRACT--�------'-�- t Owner's Name _ ,: ---------Phone- �7� city Zip .?D- Address------ -- ----- ------- - Ci Contractor's Name car- License # - 7 /'" Phone Installation will'se•rve: Residence [� Apartment House❑ Commercial ❑ .Trailiy,,•Court'E Motel -❑ Other--------- ----- -----=-- --------------- Number of living units:-`--__._`------Number of bed rooms_ _,,_..=_Garbage Grindea�-------...__Lot Size.___ - ---------- ---- . Water Supply: Public System and name-:.-:----------- --- -- -----------------'-_.- _ - ------------------ - ) -------------Private J _ __ Character of soil to a depth of 3 feet: Sand,E] -Silt ❑ Clay ❑ Peat ❑ Sandy.L a [q✓Clad Loam ❑ Hardpan 0 , rAdobe E'] Fill Material------------If yes, type,J�-------- --- _ P. (Plot plan, showing size of lot, location of'system` ,in relation to.wells, buildings etc. must be placed on reverse side.)NEW ' PACKAGE TAREATMENT €INoSEPTIC TANKr (se a it eSr` ett u csewer- available within 200 feet,] -septici`k. P .- P p � 16," r -Liquid`Depth------ __�'--------- ---- .__._- - �, � / Capacity--� O _____Type_-- -/ -----rMaterial___� c'---_--No. Compartments_._-�----------------- r. �: I Q� �.-� ��. ----------- - - ---.Prop. Line � ---- f Distance.to-nearest:vWe11 _ w �__ foundation____ LEACHING LINES.No._of Lin�s"" �__ Length of e ch kine ®-____. .____Total Length.--- - - -------------- r' > `�"�� D' Box / . "Type Filter Material ��"Z--- Depth Filter Material ____________ ___________ ____. - > - 'Distanceito nearest: Well_"___�-�_- __:____.Foundation___ ®�___:_.__ Property Line..`le �.___.____ SEEPAGE PIT jam! Depth.ezi; _;___Diameter._,.-�-W-__.__.Number----------3---------' Rock Filled Yes No ❑ I -- ----------------------------------Rock Size; �'-- -- �� ------------ I - # � Water Table iDepth. _----�--- -=----------- - - ---- Distance.to1 nearest: Well---- -------------------------___:Foundation._._.21�__'e,rt-�_c..ruop. sine-_/0------------------ REPAIR/ADDITION r__.__ .__ ----.REPAIR/ADDITION (Prev. SanitatiW Permit#---------------------------------------------- --Date---------i--------------------U------------)k A „ `-- ----- Septic Tank (Specify,Requirements)-----=...----------------- ------------------ -------- --------- ------ Disposal Field (Specify'Requirements)------------------- - ---- ---- ------------------------------------------------------ ----------------------------------------- --------- ------------ ..... -- .......... - -- ------. . .............. ------ ---- - { --------------------------------------------- --- ----- -- ---- ----- -------- ----- - ------- - .I d --------- - -- ---- ________________________ _.._._ .__.___-.__._____..________------___.____________.___._-_---------.__________________________________._ __f _111 _ i \ 1(Draw existing and required addition on reverse side) I hereby certify fhat:i have prepared this-app lication-and-that-the-work-will4be-done-in-accord ancexwith-Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health DistriwAlome owner or licensed agents signature certifies the following: , ` "I certify that in the performance of the-Week for which this permit-is issued, Isndil_nofi employ any person in such manner.as,,,,i to become subject to Workman,s (Compensation laws of California." Signed------- !-:--------------------'---- Owner ---- -- ----------- ` i-------- Title- �LP>LG (If of er Than FOR DEPARTMENT USE ONLY' , Y APPLICATION ACCEPTED BY �' --------------------- DATE ,;5 _. �f { r, DIVISION OF LAND NUMBER....... i ;_ _ ....a -:_- -----------DATE-:5_' x...11 y 1/ --- ADDITIONAL COMMENTS - - --u; ------ y ----------------------------- -------- - --------•- -- ----- ` ------- --------------- ---------------- --------------------------------------- 7- ------- -----------------------------11------ --- ------ - -- --- -- - FinalInspection bY- --- - --------- ---- ------ - ---------- --- - --------- ---- ---------------------------Date_------------ ---- - ------- ------- --------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M