77-1003 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete in Triplicate} Permit No................... ... --------------- ------- ---- ---- - Date Issued_/..�_`_`x-...___77 ----------------------------- This Permit Expires 1 Year From Date Issued G7 _ r 0--o s Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRI=55/L`OCAT1 t `� -------- ----- ��' rC �� CENSUS TRACT - Owner's Name " :__ r �T �- -------ce----- — _ _-------.Phone--- ----- ------ - �Z -------- Address - - C -----zp----! i Contractor's Name------------ ----c ----License ---Phone._________________________________ -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------- --- ----- ------- Number of living units:----)_---------Number of bedrooms.._. Garbage Grinder_---------Lot Size--------------------------_.............._.._--._--._-__.-.-0 Water Supply: Public System and name---- - ----- -- -- ------ --- ---- ---- ------ ------ -------- -----------------------------------Private Character of soil to a depth of 3 feet: Sand Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe❑ Fill Material-. ---------If yes, type ________________ �P. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) i PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth-------------------- Capacity_------------- ._________________Ca acit ___.Type-__.-.__ ____Material--------------------------No. Compartments Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line.-----------------------; LEACHING LINE [ ] No. of Lines---------------------------- Length of each line------------------------------Total Length.-------------------------------------- . 'D' Box------------Type Filter Material--------------------Depth Filter Material------------------- -------_--------------------- Distance to nearest: Well----------------------------Foundation----------------------------Property Line--------.------------------------ SEEPAGE PIT j ] Depth----------------Diameter-----.--------.-----Number-------------------------------- Rock Filled Yes ❑ No [, WaterTable Depth---------- ---- ------------------- ---- ---- -----------Rock Size------------------------------------------------ Distance to nearest: Well .___-.__-_.__---------------- ---- ---- -Foundation--------------------------Prop. Line--------------------------- REPAIR/ADDITION ____._______._REPAIR/ADDITION {Prev. Sanitation Permit#--------------------------------------------------Date----------------------------------------------) i Septic Tank (Specify Requirements)----------. ------------------��-----------------------------•--------- Dis� eld (Specify Requirements} ----------- ------- ----" � ------- ---------- ----- ------------------------------------------ ----------------------------- ----- ---------- ---------------------- �f r - --- -- - --------- ------ - ------------------- ---�---------- - �"`---- ------- ---J ------ raw existing an required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "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 to become subject to Workrn n's Campensatic laws of California." Signed---- --- -- ------ -- Owner -------- ----- --------- ---- -- - By----------------------- - - ------1`-----------------'------ ti Title _'_ ------------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- --------- ----------------------------- ------DATE .. . ------ ------- DIVISION OF LAND NUMBER. ----- ---------- DATE. ADDITIONAL COMMENTS---------------------------------------------------------I------------------------------- ---- --------------------------------- ---- ---------- ---------------- ------------------------------------------------------ -- ---------- ------------- - - - - - -------- ------ ----------------------------------------- ----------------------------------- ---------------- --- --- ------------------------------------ --------------------------- - - --- ------------------- ------------------ Date - aZ ' r Final Inspection bY:--- EH 13 24 SAN JO UIN LOCAL HEALTH DISTRICT F8S 21677 REV. 7/76 3M i