78-1030 - Laserfiche WebLink

Home Browse Search

" FOR OFFICE USE FOR OFFICE USE: `APPLICATION FOR SANITATION PERMIT Permit No.2 =1U>3 O (Complete in Triplicate) t Date IssuedlL -� _:7� __________________________._.__..___.._._._._.... ------ This Permit Expires 1Year 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: 3 JOB ADDRESS/LOCAT ON- C to - ------------------------ -------------------------------------- ...........CENSUS TRACT------ ------------------- -`-- Owner's Name -- Phone ----- --------- ---- ----------'------=----------------------- ------------------ Address------------------C4-XX -----*'r ' ---- ------ ---------- �.� � r �. City-_----y- ---- -- •� -� � ----ZiA---�-----�----�----- Contractor's Name._'_ . .--- _.- _ ._ License .#--- -- Phone--------------------- ` Installation will serve: Residence [l Apartment House ❑ -Commercial ❑ Trailer Court ❑ Number of livingits______________ _ o Number of bedros_t`_ g _______Garba a Grinder.__,_:___ .•-Lott ' units:-------- Motel Oth.er� Water Supply: Public System and name i- _=` ----- - - Private Character of soil to a depth of 3 feet: Sand ❑ .Silt❑" Clay❑' Peat E] Sandy Loam ❑ Clay Loam ❑ Hardpan Adobe ❑ Fill Material -.-___._.._-If yes, type---------------.------ t � (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 pitpermitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) ; SEPTIC TANK"'['] ;• Size___________:_ '__::.____� '" E l ------------------ ---------Liquid Depth-:------- --- -- ---- CapacitV ---- Capacity ' Type _ Materiala.: _:____°.__ No�Compartments---------------------- \' 1 i1- - ---.F�� ! _________ :_____.___ � :Distance to nearest: Well:---------------------------------------' n _ � ndation ________________Prop. Line-- LEACHING LINE; [ ] No. of Lines_ .--_ __.Length-of each line.:__`.______`!._--I""�_�~_:,Total Length .'D' Box--------- --Type Filter Material------------_---------Depth Filter Material __ , --- ------------- ----------- Distance to nearest: Well 'i Fouridation__ 'r_ ; } Property Line SEEPAGE PIT [ ] Depth----------------Diameter: Number-------------------------�___._ Rock Filled 'Yes ❑ No im } -------------------------------------- -------------- - ------------------------------ Water Table-Depho - Distance to neares#: W611';---------------------------------------- - 'Foundation -=-------- - -=------ -.Prop. Line---------------------- --- REPAIR/ADDITION (Prev. Sanitation Perm it# } w= Qa#e `---- `----- -------- --- -------------- ep (Specify Requirements)------ -------- ------------ ------------- -----------' = _ -------------------------------------- ---=M - -----------------Requirements)= ---------- Disposal Feld (Specify :- --------.. -- ---- _ -- -- --------------------------------------- ---------- --------- ----------------- --- --------------------------------------- Draw existing and'require'd addition on reverse side) - I hereby certify that l 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 bf'the'work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation 7 ws of California." Signed ---- .--Owner : . ` By--------=---------------------------- -------- = Title �-�` "i . - ---- A- �"� r 1 (If other than 6wwne4 am` FOR-DEPARTMENT USE ONLY APPLICATION ACCEPTED. BY-'_:1.y - ------- -: --.DATE ± --13 ------; - DIVISION OF LAND NUM BER-------=------ DATE.: - ADDITIONAL COMMENTS-------------------- --- ----------------------'----------------------------------------- -1 --------------------------------------------------------------------------- ------- ---------------------------------=------- ----------------------------- - -- -- ------------------------------------------------------------------------ ------ -----.---------- ------------ -. _ -- ------------ ----- Z Final Inspection by .�..4� . Date ��/ EH 13 24 SAN JOAQlA LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M t