77-557 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: FOR OFFICE USE: - ' -"t; APPLICATION FOR SANITATION PERMIT —7 (Complete in Triplicate) Permit No.___ -------------------------. - ;-- --- ------ ----- Date Issued__ -_U_-_�__ ---------------.---- ----a-------- This Permit Expires es 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 "' t, ' t ` = - -" - - - - -CENSUS TRACT r," r� Owner's Name L `� � `�`� ' - - -- - - - Pone-------------- -------------------- - �. ha Address- ---- �' " -- - City '= ' '` c F - Zip Contractors Name ;� _ "�_. t v a- ` "� f.�•,. n 4- - --- - - --------- - ----- -License # r?Sr- `' Phone_ ,_ .t3 fi Installation will serve: Residence ID Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---- ----------- --" - -- - - - -- - -- Number of living units:______ _ ------ of bedrooms_1�-_ --- Grinder__-----_____Lot Size______-4___ Water Supply: Public System and name---- - ------ - ------------------------------------------ ------------------------------------------------------------------Private ] '? Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam X 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ;>J Size-------------------------------- ---- -------------------__Liquid Depth /r Capacity- '_ -t1C%- ------Type rMaterial t _`-74;r-:- ----No. Compartments ------------------------ �_� � .. Distance to nearest: Well _______: �_`__ _____________________Foundation_______________________.Prop. Line -_-____________________�' LEACHING LINE Y►] No. of Lines �_ Length of each line ___ _Total Length '____ 'D' Box Type Filter Material_ - ``+_____ Depth Filter Material_ - ---------- ___ Distance to nearest: Well______� S"__"_________Foundation___'''_'_�______________Property Line___ ^ _�___._______________ SEEPAGE PIT [ ] Depth__---_____ -----Diameter_____------_.------Number___------------- ------------- Rock Filled Yes ❑ No ❑ WaterTable Depth ------------------- -----------------------------------Rock Size----------------------------- ----------------- ; Distance to nearest: Well _---_____-------_ -------- - ____-------------------- Prop. Line___----------------_._____ REPAIR/ADDITION (Prev. Sanitation Permit#___._____-__.__.__.______-_____________-Date_________.__-__----_ ---------------- -) Septic Tank (Specify Requirements)__._ -- - ----------------------- - ----------------------- - ----------- - -Disposal Field Field (Specify Requirements)_, - L-------G+/`tG - --------------- --------------------------------- - ------------------------------- -- - ----- ---- - ---- --- ----- -------------------------------------------------------------------------------- ----------- ---- ---------- --------- ------------- -------------------------------------------- ----------- -------------------------------------------------------------------------------------------------------------------------------------------------- (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__ � A, 4 ; G', aM' 5'e".A --- ---Owner r 1 BY ��"t r Zhan - --- - ---. it a-- - -fT#"ofttie owner) 12 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_.. . ------------------------------------DATE - ------------------------------------- - ------------------------------------- DIVISION OF LAND NUMBER________________ __.DATE..__________ ___ ----------- -------------------------------------- -.t - ADDITIONAL COMMENTS-- --- --- -- - --- ------------------------------------------------------------ ----- ----------------------------------------- --------- ------- --- -- - - ----- --------------------------- - ------------ ---------- --------------------------------------------- ----------------------------------------------------- ---------------------- - ---- ------------------ - -- ----- --- ------------------------ --------------------------------------- - ---------------------------- r- - r -- FinalInspection by:-- - --- --- ---------- ---------- ----- ------------------------------------------------------------ Date---------- -- - ---------- ---- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M