Laserfiche WebLink
FOR OFFICE USE; <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------I.... ............ �,f4 � <br /> (Complete in Triplicate) Permit No....................... <br /> ""'•"-.•••••-.-••-.•••...._..... ............. ...... This Permit Expires ] Year From Date Issued Date Issued__.... I I <br /> Application is hereby made to.the Son 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/LOCATIO ......I-loo <br /> .... --------------------- ---------CENSUS TRACT.--------------...._.:---... <br /> -- <br /> Owner's-Name..... <br /> ....... -----------Phone_lq ......... <br /> ------ ---------- _&Y -9 <br /> Address-- io�J%......... ............ ------- <br /> S <br /> -- ---- ........�� 7,� 7,..'Phone---q4�- <br /> Contractor's,Name._� b <br /> License #.jc .... --- <br /> Installation i will serve: Residence Apartment House ❑ Commercial E] Trailer Court E] <br /> Motel ❑ Other--,.----------- -------------------- <br /> Nuriiber of lit <br /> units:.--.-.1.._.._--Number <br /> ving of bedrooms.--43.... Garbage Grinder............Lot Size---.-_- _�. ....... . . <br /> Water Supply. Public System and name -------------------------- ................. L---------- ------------------------------- <br /> Character of soil to a depth of 3 feet: Sand E] Sift E] Clay E] Peat 0 Sandy Loam El Clay Loam 11 <br /> Hardpan EW Adobe,0 ' Fill Material ....If yes, type-------------------------------- <br /> (Plot <br /> ype--- ---------------------- <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 /> 11 IC <br /> PACKAGE TREATMENT SEPTIC TANK [1-r S, <�p <br /> ------ -------- -------- ---------------.Liquid Depth---- <br /> C p .......... <br /> a acity� -------Type._-P 4;;. 'M <br /> ------------- .. ......No. Compartments-----._. <br /> Distance <br /> ompartments-------- <br /> Distance to nearest: ...... .. . ...........Foundation---149 ... ......Prop. Line-��__t........ ------- <br /> LEACHING LINE Lj' No. of Lines (21.........:..._:_..Length of each Total Length -------120. <br /> -------------- <br /> 'D' Box.......-.,..Type Filter Material. 1PA-4le—Depth.Filter Material..._-'._ _/.S......... ------------------ ------------ <br /> • Distanc5 to nearest: Well--- ._.-..Foundation_____r�,? ----------------Property Line...-.----- -- <br /> SEEPAGE-PIT LK Depth..�� Diameter___3!�_".....Number.........42L------------------ Rock Filled Yes V' No[] <br /> Water Table Depth-------1-616............ .........................Rock Size_ - - ----- ----------------- <br /> Distance to nearest: Well .3.0.0.. - I . <br /> ......... . ... -------------- Foundation. 6-16... .....Prop. Line--_.. <br /> REPAIR/ADDITION {Prev. Sanitation Permit#----------------------------------- - _-----------Dcite-------- ......... ....... ----------- <br /> SepticTank (Specify Requirements)_.----- ----------------------------------- -- --------------------------------- ........ --------------------------- ........... <br /> Disposal Field (Specify Requirements)..._...........:...... ........................I..................4------------- .4........................................ <br /> ---------------_--------­------------- .............................................. -- ------------ ------------------------------- ...... ............ ......................... <br /> ---------------.................................... ------------------------------------- ........................I——.......................... ----------- ------------ ------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared 'this application and that the work will be done in accordance wifh­San Joaquin County`""' <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home.owner or licensed agents j <br /> signature certifies the 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 <br /> to bec ombject to Workman' Compensativ*n laws of California." <br /> Signed.,..(/C. '.,-Owner_ <br /> ................... -------_-------( <br /> Title.. .......... -- ---- <br /> By.......... v,/--- . .... ............. <br /> (if other than owner) <br /> OR PE!ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----....... ......... <br /> . ...... ...... -------------------------- ............ DATE <br /> DIVISION OF LAND NUMBER...... ... ......... --------DATE.... <br /> -------DATE....--------- ---------- ------- -------------------------------------- <br /> ADDITIONALCOMMENTS ... ........ ------------------_- ...................... ------------------- ..................... ------------------------- <br /> ....................... .... . .......... ....... .............. ...... --------- .................................. ....... ...... ........ <br /> -------------------- ........... ------------------- --------- -------*-------*......................................... -------------------------------------- <br /> ------­------­ 4----------------------------------- <br /> Final In Spdtjon by: .... <br /> I-- <br /> - <br /> ------------------------- <br /> -------- -------- --- --- ..........­....... <br /> ----------------7------------------ <br /> EH )3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S.21671-"7/76 3M <br /> L4—,J <br />