77-820 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: SCANN IGOR OFFICE USE: =---1-..Y APPLICATION FOR SANITATION PERMIT FoLo (Complete in Triplicate) Permit No.__ __-___-__- __-------- __-'-- -------------------- Date Issued./,�-/a-".-.77 ........ ..._ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _QZ ^'L-- ---- --------- --------- ............ CENSUS TRACT.. -- Owner's Name -------------- .... - � --------------------------- ---.....------------- -----------Phone-------------------------------- Address......._ .. .11S r- ---- - - - --- ----- City. _.. -- - --Zip--------- - Contractor's Name - --- License #.. /' S -2L _Phone.. - - Installation will serve: Residencpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units:-------�.--.__Number of bedrooms-_AX ----Garbage Grinder.___-----Lot Size----_...-.._-._.-.___ Water Supply: Public System and name---------------------------------- ------------ --- ------ -------------- --------------------------------Private H� Character of soil to a depth of 3 feet: Sand E] Silt F] Clay C] Peat E] -Sandy Loam /Clay Loam❑ Hardpan ❑ Adobe ❑ Fill Material-._-____If yes, type____ --------_-------------- (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 see age pit permitfied if public sewer is available within 200 feet,) i ----- Depth..-_-...- . Capacity �BQ._-.__Type. --Material_ c......No. Compartments / Distance to nearest: Well.._--.-_moo ---- --- __,__Fo/undation.._1� _.-_Prop. Line----- _. LEACHING LINE [(] No. of Lines.---------3-------------- Length of each _-_Total Length 'D' Box___ _.--Type Filter Material.---s/._4 ----.Depth Filter Material----- ______-_--_-_.._-..__.._ Distance to nearest: Well _100 Foundation Property Line__-__-��__m �___. SEEPAGE PIT (% Depth_. r2 .Diameter__/ Number _5 Rock Filled Yes{KNo Water Table Depth------------oFe�----i_-------- :.- ------ --- Rock Size--_-Ila___,�1 ------------------- Distance .-----.------_Distance to nearest: Well____,ljT6l - Foundation. Prop. Line_-S_, ___._.- REPAIR/ADDITION (Prev. Sanitation Permit#_______.._-_------- ------ ..............Date_____:._................ Septic Tank (Specify Requirements)--------------------- --------------.---:------------------------------------`----------------------------_---------------........ ......------ i DisposalField (Specify Requirements)-------------_------ ----------- ----- ------------------------------------------------------------------------._..------------- ---------------- -----------------------------------------------------_._.-----........... ------------------------------_..----- -----`----------.....---------------------------._----------------- ........ _..---------------------------------- - ----_..------ - ----._. .-------- ------ ._..------ ----......--------------- -.......-..---- -- ----._....... (Draw existing and 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 Workman's Compensation laws of California." Signed_ - - -- - ----------------- --- - - Owner By......_........ . . -------------------- r ..11t �Title.�N�'itfnar.'`"_ - - --- - - - ...- (If other than owner( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -1_ _ DATE _— DIVISION OF LAND NUMBER- ... --_ ------- __.. DATE ___ - - .__ _.-_..... ADDITIONAL COMMENTS____ _ - _______ ---- - --- - - - - - --------------- - - - - - . .......... - -- ---- -- - - ------------------- -------- --- ---- --- --- -_.......------------ - ------------ - - - Final Inspection by:----- .-..: - - - - ........ Date... ---- ----- EH 13 24 SAN JOAQUIN LOCAL H ALTH DISTRICT F85 21677 REV. 7176 3M