Laserfiche WebLink
FOR OFFICE USE: �� FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------ -------------- <br /> (Complete in Triplicate) Permit, No. -: <br /> .. '...-...... Date issued_.�: .:.7 <br /> ........................ ........... This Permit Expires I Year From bdte (ss�ued I� p —04C7_ZZ <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install thel#V described. <br /> This a plication 1s,made,4'n-com I.iance with County Ordinance No. 549 an existing Rules and Regul z ,� <br /> JOB"ADDRESS/LOCA'TION.... <br /> �� 4 ..AM. ...-.CENSUS To <br /> Owner's Name.... .L:. Phone,..... . . <br /> 4.--• ----- ------- - - I� <br /> Address...- p__ ✓ (�'%... --- - - - -- ------ --- City---- ._...-------- ----------- ..zip--- <br /> ...................... /,q� <br /> Contractor's Name. �J.�.. �,r- ............... :.: License #.3_,! �171 _ Phone ..A� .41� <br /> M_ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial �k Trailer Court ❑ <br /> Motel ❑ Other................. . f <br /> Number of living units:------ ---------Number of bedrooms.-..........Garbage Grinder------------Lot Size....."- ... a <br /> Water Supply: Public System and name...-- �- •• - - • ----�............. . ....... -�-.- ........ ................... ...-. �- -�-----------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peau[-1' "a Sandy Loam ❑ Gay Loam [ <br /> Hardpan ❑ Adobe ❑ Fill Material.. .... ....If yes, type.:�%-------------------------- - } <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 /> PACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size - --- -. [--- ---- -.� ------------------Liquid Depth..-�------- <br /> Capacity/. .....Type.. Material. ---------No. Compartments...-- -------------© .`! <br /> Distance to nearest: Well.......�Q!'�.... ................. ...Foundation.----11 .... ..... ..Prop. lne-....0.7 <br /> ._ <br /> I <br /> e -------- <br /> N <br /> LEACHING LINE No. of lines Length of each line ... . .... Total Length �;a_ .--- ------ - <br /> .......... .. i y - � 1i1 :..'D' Box............Type Filter Material Depth Filter Material.. . <br /> A Ale X j�� Distance to nearest: Well-..,--�� :(ter...... ..Foundation.....�.�...-.... - - Property Li h e._� � M <br /> M <br /> SEEPAGE PIT ( ] De Diameter-----------...---_Number....- ------ Rock6 Filled Yes No [� <br /> Water Table Depth-------------------- ---- ...--..Rock Size.... <br /> - IM <br /> Distance to nearest: Well------/P.0............:.........Foundation_ -3._ ". ......Prop. Line..... ---------..---_:. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------ --------------------------- ---- --- ------Date----------•• --_-------......------------ ] <br /> Septic Tank [Specify Requirements]... - ..........:.............. ...... - ----------------- ------- ---- <br /> I` f <br /> Disposal Field {Specify Requirements) ................. --. 1--------•- --------- ------ ;F <br /> ............. ------ - --- ---- ---------- ..........-.._----------- --------- ...--- ..... I� ------ ------- -- --- <br /> ---------- ------ ----- ---------------- - - .. ...--- -------------------------- ---------- ------.------------------. <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 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: 11 <br /> ` <br /> "1 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 to Workman's Compensation laws of California." <br /> Signed---.. .....---- Owner <br /> .. .. Title- --- ------....................... . . <br /> By..--..... <br /> (if other than owner) <br /> FOR DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY....... --- ---- ---- ---------------- ------ DATE.... . .Z�. ..7�...... <br /> DIVISION OF LAND NUMBER_........._ <br /> I <br /> ADDITIONAL COMMENTS-- ........ ................. <br /> -- - .......... <br /> - <br /> ------•-------------- -------- ----- ------------------- - ---------- ------- ----- -----------------------....------------ .....-•------ .----- <br /> - ---- - - ---------------_- - .`.._...- <br /> t � Z M 1.. ...... <br /> Final Inspection by..... ........ . . _... ...... �NJOAQUIN <br /> -------....------- ....... - -------- <br /> EH 13'24 LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M <br />