Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> >� APPLICATION FOR SANITATION PERMIT <br /> �36 . <br /> (Complete in Triplicate) Permit No.__..7 --...- <br /> -----------------------------------_­................. <br /> Date Issued..5:.�--.-' <br /> •....................... This Permit Expires 1 Year From Date Issued <br /> F 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�:ounty Ordinance No. 549"and existing Rules and Regulations: <br /> JOB ADDR --, <br /> ESS/LOCAT -- ..�---�-� ...... ...... .- -----------------------------------------------.--- -.-...-.CENSUS TRACT------------- <br /> Owner's Name...: ..... ....... Phone... <br /> y� - -.-------- <br /> Address.__// .�(./ = -- - --- ------------------- -------------I -city............ ----- -Zip -... <br /> k Contractor's Name...-- �- .............License #..`. v.- //-.... .Phone__. 1-- <br /> Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other..... ........................................ <br /> Number of living units:..... . ......Number of bedrooms :�-.`..Garbage Grinder:'= ..--..:Lot Size.--9.1 _A.L��� .�_-.__,--._....___...,.... ; - <br /> r Water Supply: Public System and name................ .. ............. Private E <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay❑ Peat,❑ Sandy Loam ❑ Clay Loam El <br /> Hardpan ❑ Adobe ❑ Fill Material .�.�-;. If yes, type-............................... <br /> I (Plot plan, showing size of lot, location of system in relation to wellsi buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepageFp' it permitted if public.sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size... ., ...6 X.l .-_,... .- ___Liquid Depth,- -...__...- <br /> Capacity.1/V.O.�-...-Type..:�4- ..........Material--.- dli__ • --:No. Compartments--- ------.---- <br /> Distance to nearest. Well........P Ze! L.. .........Foundationr _.- ,P. .............Prop. Line--��--.-....-.---... <br /> LEACHING LINE [ ] No. of Lines _... ......... Length of each line..---- Total Length ..t_7lo--------------_--------.- <br /> 'D'.Box....f....Type Filter Maferiai.._.../ Depth Filter Materiae,-- -----------------_------------------ ---- ------ <br /> Distance,to nearest: Well....- ....... Foundation-----/Q--------- -Property Line...-$5...----.-------------------- <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 /> REPAIR/ADDITION (Prev. Sanitation Perm it',#------------------------........... .........-----.Date...............................`..-----....... <br /> ) <br /> i <br /> Septic Tank [Specify Requirementsl.------------------- ----- <br /> i = =--------------- - ---- <br /> Disposal Field (Specify Requirements)__-----..... .:.:.. ..... ------- <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: <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 /> M to become subject to Workman's Compensation laws of California." t <br /> Signed-_ = = ..... Owner <br /> i BY .. !/l- •-------------- - Title. <br /> i (If other than own r) ' <br /> k <br /> N FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_.......... ........... e0p, ............ ......DATE - `J '.7d.:........... <br /> 1 DIVISION OF LAND NUMBER------ -------- ------ --------------------- -- DATE...... ............................_..----.... <br /> ADDITIONAL COMMENTS--------- ---------- - - --- .... ........ -- <br /> ...................-.... ---. ---- ----------- •------------------- -------- ...-..------------ <br /> ----------------------------------------- --------- --- -- _ ..--•--....._-------- ..-----.. <br /> ------- �. . .. ------- ------ ............ ------- <br /> Final Inspectron b � •�°���- ------------------• ---...-..------......... -- --•-- ----------•-- - � <br /> Y 4 _. _.... . Dater <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fo 21677 REV. 7/76 3M <br />