Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - <br /> (Complete in Triplicate) <br /> Permit No.-)" _~s-.5.4 <br /> - ---------------------- --------------------- ----- ---- ' <br /> l Date Issued_._`"; .(0-7 f <br /> ------------- w---- - -- -- ..ter <br /> This Permit Expire s`1.Year:F�on1 Dat'Issued <br /> --- - --- --- <br /> ..r. _ .. r <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 /> tSS/LOCATIO.A -_CENSUS,TRAC --------------------------- <br /> JOB ADDRE ; <br /> Owner's Name. - 1---- --- - ---- Phone.--' <br /> y. ------------- - .r^� I"" <br /> {' Address. - l -- -Ci -...--- Zip- `� � �- <br /> . .. _ ri , <br /> e- <br /> Name-:_"- UcensePhon ----------- <br /> contractor's -.._ . <br /> k _ <br /> ❑_ P cial ❑ ?Trailer Court ❑ <br /> _ce A❑artmentHouse Comme----------------- <br /> j- <br /> r <br /> i Installation will;serve: Resides Motel Other"-" -__ tis- - - <br /> - --------- -- <br /> T k <br /> Number of living units:-___----_-__--Number..of.b6drooms <br /> ----- --Garbage Grinder-_ Lot,Size"-___ i._____".-"- <br /> i <br /> ------ ------- -- <br /> Water Supply: Public System.and name--.-..''---- -.-' -- -=------ ------------- -------------:-.:----._.- - ` -Private <br /> F. Character of soil to a depth of 3 feet: `, Sand Silt❑ 'Clay ❑ ' Peat ❑ Sandy Loam ❑ Clay Loam <br /> k o i-I d <br /> Hardpan`g Adobe❑ Fill Material-------------if yes, type--- --------­__---.-.------ <br /> i <br /> . (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.,must be placed on reverse side.) <br /> I NEW INSTALLATION: (No'septic'tank or see ge pit permitted publicewer is available within 200 feet,) <br /> TREATMENT [ ] SEPTIC TANK [ Size- 1,� -_---i - ----------------Liquid Depth--------------------------- <br /> PACKAGE <br /> Capacity- ©D =Material-_ -ll� -_rtNo. Compartments?--:- ---- <br /> E / l i" QProp. � <br /> Distance:.to nearest:IWell.; _� Q-""" .----.-EFoundation Line--_ _. <br /> [ . ! .-----.Len . F ` � T g - <br /> LEACHING LINE: [!� No, of Lines_-,•-:_,._'_„:,._ -_.,- : gth,of each line._,._--- _._4.-- _-.Total Length.- - -- ------ <br /> LEACHING j <br /> D' Bokr_. .Type Filter Material - s __Depth Filter Material--_--_ -: <br /> Distance to nearest. WeIL` = !- --. Foundation --"L X11 r-- ""--Property Line ----. -. -_.Q <br /> SEEPAGE PIT [� Depth-. 2. "-Diameter:--" ;-.-_ -Number---:---- ""____---- kF[l e <br /> Y s o <br /> =----- : Rock ,Size <br /> nearest: Weff.'_�_.;---.ot-.`� - f - ' <br /> Water Table.De th___"------:--_::--- _<- -- ___-. <br /> -Foundation Prop. Line - -----------f-- <br /> q _ Y <br /> REPAIR/ADDITION (Prev.-Sanitation Permit#-- ----=-:=--=----- -------------==-------- 'Date------------ --------------=---1 <br /> Septic Tank {Specify Requirements)--.- ...:...........� ;• ----------------------------------------------- ;.3 <br /> - 5 <br /> F4 --- --------- ------------ V--------- -- - <br /> Disposal Field (Specify,Requirements]----- ----------�-------- ---- -----=--------------- - ------------- ---------- <br /> i <br /> ---- �' <br /> ! �{Draw existing and required addition:on' reverse side) ` <br /> I hereby certify that I have prepared this Jdoplication and that the work will be done.in••ciccordance with San,. Joaquin County <br /> Ordinances, State Laws,an`d"`Rules-and­Regulations of;. the}_San Joaquin Local�Health District. Home owner or licensed agents. <br /> JJ,y . <br /> signature certifies the following: . , _.. <br /> a <br /> "I certify that in the performance of;tFie.work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's..Comp nsation laws of California.'.' . - <br /> i Signed---- - -'- -- ------Own <br /> $Y er ' <br /> ; --------- ----- -------------------------.---------- - ------- --- t , <br /> 'Ti le - <br /> (If'other than owner) <br /> FOR,DEPARTMENT USE ONLY ' r <br /> y APPLICATION ACCEPTED BY"- -- -- ' <br /> ` DATE <br /> I DIVISION OF LAND NUMBER.------------ ------' - -:--- ----------------------------DATE-,-.--. <br /> l <br /> ADDITIONALCOMMENTS----------- --------------------=------ ------------------------------------------ -----`---------------- --- --------------------- ------------ ----------------- <br /> =--------------------------- - ---------------- --------------."----.----- --_ -: ----------------------------------------------------------------- <br /> - ---------- --r+ l/ - <br /> -- - - --- <br /> -- <br /> ' i <br /> Final Inspection•by:-- --- " - Date. 7i - <br /> EH 13 24 J SAN JOAQUI LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />