Laserfiche WebLink
FOR OFFICE USE: k1FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> �j Date Issued_/,e:f/-,?,r <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 application is made in with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI <br /> ®f'-7. . - �u - .--------- --------------- CENSUS TRACT <br /> Owner's Name------------ -----Phone-------------------- ----------------- <br /> 69� <br /> ---------city---------------- - --- Zi <br /> , �� ----- CitY------------- - p = <br /> Contractor's Name____________ ____ ____.__� -------License #--- __Phone.-__-..--________-_________-----. <br /> Installation will serve: Residence❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---��_J__?_-t_ ___ '" A <br /> Number of living units:----/----------Number of bedrooms---4+2---_Garbage Grinder------------Lot Size____ --- '`-' jr-' " ---------____________ w <br /> Water Supply: Public System and name------------------ --------------------------------------------------------------------------------------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand E] Silt E] Clay E] Peat EJ Sandy Loam [:] Clay Loam ❑ <br /> Hardpan [ Adobe ❑ Fill Material------------ yes, type______________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seegage pit permitted/iiff`public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [�J/ Size_y� :� '____tel__�_ _r��_--_______________Liquid Depth__------------------- <br /> Capacity--/,;26-6 <br /> __________-_____ <br /> Capaeity__ „�Q�l--------TYpe__� 4__V_J tarial----�p '''� ----No. Compartments-----G -------------------- f' <br /> Distance to nearest: Well _.. 11.__--_.___________Foundation_-_-��----------------Prop. Line_____________________1 <br /> LEACHING LINE (/'/No. of Lines------------G --------. Length of each line_-----,_ -a__ _Total Length___ 16___________________________ <br /> D' Box----- <br /> -------Type Filter Material___-.-I ----Depth Filter Material--------ly_-----.-___----____-----_____-___------------- <br /> � <br /> Distance to nearest: WeIL_____40_._........Foundation--------/_a__/----------Property Line________1e________________ ----- <br /> ------------- <br /> SEEPAGE PIT [J/� Depth--- _-/_Diameter----_ _ _tr.-Number------------�-------------- Rock Filled Yes No❑ <br /> / / / /i <br /> Water Table Depth----------------�0?------------------------------.Rock Size---1 ------ --1_ <br /> to nearest: Well ---------------Foundation_---- ___-.Prop. Line_____�_I,-------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-..._-_-___- -___. ---_----___-____-_.Date---------------------------------------------- <br /> Septic <br /> ______ __Septic Tank (Specify Requirements)------------------- -------------------------------------------- ----------------- :----------------------------------------------- --------- <br /> Disposal Field(Specify Requirements)-------- ---- ---------------------------------------------------------- `-------------------------------- ------ <br /> ------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- <br /> ---------------------- -------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 /> to become subject to Workman's Compensation laws California." ,A <br /> Signed---------------------------- ----------------------- ----Owner <br /> By------------------------ - -' <Title--------5;Z -_ ���JJJJ <br /> -- ---- ----------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEDBY-- -t --------------------------------------------------DATE. =�� �/-�------------ <br /> DIVISION OF LAND NUMBER---------------------------------------------------------------------------------------------------------DATE------- ------------------------ <br /> ADDITIONALCOMMENTS------------ ------- ------------------------------------------------------------------------------------------ --------------------- --- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------ ----------------------------'------------------------------------------------------------------------------------- <br /> Final Inspection by:--c-.--- ----- - ------------------------------------Date-/°- -/ Z--. �X ------ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 211677 REV. 7/76 3M <br />