Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION.PERMIT <br /> .................................. <br /> ~ `(Complete in Triplicate) Permit No..... . :�. Z <br /> -------------------------------••---------....---....-..- ��k Date Issued_.6"7".~_7-y <br /> If •-•••---•••-•-----••--------------- .... This Permit Expires 1 Year From Date Issued <br /> r 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_.. �d ._.. <br /> - - -----�• - -------- -- ----- -• •-- --- ---------._ .._...--•-------------CENSUS TRACT....__............ ........... <br /> I Owner's Nam .-. ....y2�? 40 Phone. ........ <br /> r <br /> Address-- ___ :f. <br /> Q _ City ___.Zip-- <br /> Contractor's Name Al- d ............License <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---- - ----- -------------------•... <br /> Number of living units---- -----------Number of bedrooms__.. Garbage Grinder------------Lot Size.. ' <br /> Water Supply: Public System and home... .... _----- -------- - Private ' <br /> Character of soil to a depth of 3 feet: Sand E] Silt El Clay ❑ Peat❑_ Sandy Loam ❑ Clay Loam ❑ <br /> ! Hardpan'❑ Adobe Fill Material... If yes, type _._-_-----__-.--_..._..- <br /> a <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) q� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) {— <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size ----------------------------------------- ------- -------Liquid Depth.'--... ------- ...... <br /> Capacity......- ...........Type------------...........Material...------....-=--1' ------No."Compartments------ -------------- --------'"", <br /> ` Distance to nearest: -- ---------Foundation....._ ... ...Prop. Line........................ <br /> LEACHING LINE [ ] No. of Lines..............-_..............Length of each line --------.......------------- Total Length .......................----.---- ..._._ <br /> 'D' Box...........-Type Filter Material................... Depth Filter Material..-.----.---------..-----.------------.-.------- ----- •-----. <br /> Distance to nearest: Well----------------------------Foundation----------------------------Property Line ..................................... <br /> SEEPAGE PIT [ ] Depth_.......... ...Diameter--------------------Number--------------------'.:......... Rock Filled Yes ❑ No ❑ <br /> Water Table Depth------------------------------ ---- ---- ----- ------ ---Rock Size...................... ---------- ...-------- <br /> Distance to nearest: Well_------- ------_....................Foundation----------- -._.Prop. Line........................... <br /> . <br /> REPAIR/ADDITION (Prev. Sanitation Per 't#--- --------------------- -------------------- Date._..- _ •--.-.----. ) <br /> Septic Tank (Specify Requirements)...... <br /> �' <br /> Disposal Field (Specify Requirements] = `1 --------- - -- ------- ----_--_ <br /> . (Draw existing and required addition on reverse side) <br /> f I hereby 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 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 become subject?a-Z6rkjnan'sjAjpm tion laws of California." <br /> Signed....=-. .... . Ownar <br /> -- - <br /> ` <br /> By.................................................j <br /> Title <br /> Of other than owner] <br /> : FQR DEP RTMENT 5 ONLY <br /> APPLICATION ACCEPTED BY..........._ DATE............ .. a <br /> ' DIVISION OF LAND NUMBER.------------- ----------- ....DATE---- ---•-- ...................... <br /> ADDITIONALCOMMENTS........................... ------------_---•- --------- ------------------------------..................................................... <br /> .... <br /> ---------------------------- --- ------- ------------------ ------------------------------------- ....... ---------- ---------.-...--------------------------------------- ------------------ <br /> -------------------- .......... -------- ----... ------.._.--------------------------............................._...----------------------------------------------- <br /> ................ .............. ....... . .-) <br /> Final Inspection by;---- ` ------------------- ---------------------- �Z <br /> � - 7-.. ....--- <br /> Date <br /> l EH 13 24 ` �FGS 21677 REV. 7/76 3M <br /> SAN JOAQUIN LOCAL HEALTH plSTRICT <br />