Laserfiche WebLink
r <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SAN IYATIOh(PERMIT <br /> ---------------------------- <br /> (Complete in Triplicate) Permit <br /> ---------------f�.-- - - --- - <br /> Date Issued__ <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 compliance with County Ordinance No.549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION--- bY/ U S' - --------------------------- -------CENSUS TRACT---------------------- -------- <br /> Owner's Name------ ---------------------------­­-----------------------Phone------- <br /> ----3------------�--j--- -q------ <br /> Address-.-. <br /> - <br /> ---- <br /> Address-- -- -------- -------- ----------- ------------------------- - City-----------------------------------------------ZiP------------------------ -- <br /> ---------- - <br /> ------------- ----License _-- ---- -- <br /> Contractor's Name-- <br /> / _ G <br /> Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ❑ <br /> Motel ❑ Other----------------------------- -- -- <br /> Number of living_units:----- __,_Number of-bedrooms---� _.__Garbage Grinder------------Lot Size________ ______.____. _ -_-.____-__-____.._ <br /> WaterSupply: Public System and name-----------_------_----------------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand _ <br /> Silt F] Clay E] Peat El Sandy Loam ❑ Clay ❑ <br /> Hardpan E] Adob ❑ Fill Material---------- yes, type-------------------______C-I-- Loam- <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 seepage pit permitted if�blic sews ' available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [I S' e__ _ !7!:_ ------_ --j'r--------------Liquid Depth.____` --------------- <br /> Capacity-- <br /> _________.____ <br /> Capacity--�'600_'._T-- ----���aterial__ o. Compartments-------^X ..1----------------- <br /> Distance to nearest: Well-______._ b_8_.__.----------------Foundation--------la------------Prop. Line!t---i��-_----_-- <br /> LEACHING LINE [ ] No. of Lines________ _------------------Length of each line_ _ ___ Total Length _-_`a_� ____-____-_______ <br /> D' Box___ _ ype Filter Material----- Filter Material______�.L/_____.______________--------------------------- 4, <br /> _- <br /> Distance o near"est: Well_=-___l_d_ _________Foundation__________._�^�'____-__.Property Line______�"�-________-------__. <br /> SEEPAGE PIT [ j Depth------------__'dip ter.':_._--------------Number-------------------------------- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth------- �- -------------------------------------- ----Rock Size------------------------------------------------ <br /> Distance to nearest: Well------------_------------------------------Foundation--------------------------Prop. Line_-_________________________. <br /> REPAIR/ADDITION (Prev. Sanitation Rermit#__-----------------------------------------------Date______.-_______.___________----------_----) <br /> Septic Tank (Specify Requirements)-! <br /> ------------ <br /> .Dis osal Field(Specify Re uirements},___.______._______ i.______________-----------_-- - . -------- <br /> (Draw existing and rectuirel addition on reverse side) <br /> -- h <br /> I 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 Sari Aoaquin 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 isi issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed <br /> ------------- - --------I------------------------------- ------------- -------Owner . f� <br /> By----�"' �% - �wr) <br /> Title-.-- <br /> FOR <br /> itle <br /> (If other th <br /> FOR D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ---v77-- --- - -- ---------- - - ------- ------------------------- --------------------------------DATE. " 7 <br /> DIVISIONOF LAND NUMBER----------------------------------- --------- ----------------- ------------------------------------------DATE--------------------------------------------- <br /> ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------- <br /> --------------------------------------- ------------------------------------------------I----------------I----------------------- <br /> --------------------------------- ---------------------------------------------------------------------------------------------- ----------------------------------- - ------------------ <br /> ------------------------------------------------------------------- -- <br /> � <br /> ----- ------•--------------- -------------------------------------------------------------------,--------------- - <br /> ----------------- <br /> ------------------- <br /> -------------------------------------- y <br /> ------------- -- - ----- ------ ---- ---------- ------------------------------------------------- - � <br />