Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ------------------------------'------------------- ------ <br /> - - <br /> (Complete in Triplicate) Permit <br /> ------------------------------------------------- Date Issued_;�-?l9: 9 <br /> ----------------------------------------------- - This Permit Expires 1 Year From Date Issued <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 appli4 ion is ad�in comp ' n,,, �e jthsCounty Ordinance No. 549 and existing Rules and Regulations: <br /> ('000 <br /> �a,-"-L'{ /}tci �� --- --- - �Q ' CENSUS TRACT <br /> JOB ADDRESS/LOCATIO //_J_____- � Cfi'�� <br /> Owner's NameL�1.._ - --------t------ -- ------------Phone - <br /> f.� , <br /> Address ./, /�- Ju� City -- -- - �'-------------------------Zip---------- ------------------ <br /> .�Contractor's Name--- -- - �-- -- - ,�-e.--- - - --=��-`�-- p'--A�License Phone---------------------------- <br /> Installation <br /> ------- ----------- ----- -Installation will serve: Residence Apartment House ❑ Comm tial Trailer Court ❑ <br /> Motel ❑ Other-------- <br /> Number of living units:------- -----Number of bedrooms.` arbage Grinder__`_X.___Lot Size---------------------------------------------------------- <br /> Water <br /> --.______________________ ____._______._____Water Supply: Public System and name----------------------------------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet Sand E] Silt E] Clay [:1Peat ElSandy Loam E] Clay Loam E]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.)' `` A <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-------------- <br /> ____________.- -_Capacity_------------------Type-----------------------Material------------ -----------No. Compartments------- -------------------------- <br /> Distance to nearest: Well-------------------------------------------Foupdation-------- -----------------Prop. Line------------ ------------ - <br /> LEACHING LINE [ ] No. of Lines ___________--___.Length of each line------------- _-'-----------Total Length.____________________________________p_ p <br /> 'D' Box__________Type Filter Material-------------------- Filter Material-------------------.--------------------------------------------- <br /> Distance to <br /> ------------.--------------------------_-.Distance_to nearest: Well----- _ _ ----------.Foundation----------------------------Property Line------------------------------------ <br /> SEEPAGE <br /> ______ _______ ___________SEEPAGE PIT [ J Depth__ ___________Diameter---------------------Number--------------------------------- Rock Filled. Yes ❑ No ❑ <br /> WaterTable~Depth-----------------------------------------------------------Rock Size-------------------------------------------- --- <br /> Distance to nearest: Well .__________r_____--_-------------------Foundation--------------------------Prop. Line--------------------------- <br /> REPAIR/ADDITION <br /> ________.__ -_.-_REPAIR/ADDITION (Prev. Sanitation Permit#------------------- ----------------------------D'ate--- -------------------------------------------) <br /> Septic Tank (Specify Requirements)--------------------- ----- --------------------------- --------- <br /> Disposal Field (Specify Requirements)-------------- - - �------------------------------- ----------------------------------- <br /> - ---- - - ----- <br /> ------------------------ <br /> ------ ----- , <br /> , _X L--------------------------------------------------------------------- <br /> y ---- --------- - <br /> (Draw existing and req fired ditio n reverse side) , <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San'-foaquin 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 to Work 's Compensation laws of California." <br /> Signed---------- ------ - 7-------- - ---------Owner , <br /> BY - �2 . c=-�--Title--- - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY I - -----DATE - ------------ <br /> DIVISIONOF LAND NUMBER.-------------------------------- -----------------------------------------------------------------------DATE----------------------------------------------- <br /> ADDITIONALCOMMENTS------------------------------ -------------------------------------------------------------- ----------------------------------------------------------- <br /> ------------------------------------------------- ------ <br /> ------------------------------------- . <br /> - ------------ - <br /> Final Inspection b � A� / ------------- ---- -- ----------Date------ <br /> EH 13 24 N JOAQUIN LOCAL HEALTH DISTRICT f&S 21677 REV. 7/7 <br />