Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
FOR­OFFICE <br /> OFFICE USE; FOR OFFiS E USEr. <br /> APPLICATIOWFOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No................ <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-a1permit to'construct and Jrlstall the work herein described. <br /> This application is made in compliance with County Ordinance No.'549 and existing Rules and Rdgulotions: <br /> .»� - <br /> JOB ADDRESS/LOCATION. . _- <br /> _.CENSUS TRACT-................... <br /> ...... <br /> Owner's Name......... .... --------------------Phone.... ,..---. -- -- .. <br /> i <br /> Address-... .........3 ..City......-­­---------------"---------- -- -Zip------------- ------ --------- <br /> Contractor's Name_--:...__ _ tr�t License #;02r/.�/.-Phone. <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> 1 <br /> Motel ❑ . Other.......... <br /> Number of living units:.....j_....-"--Number of bedrooms... Garbage Grinder___'........Lot Size.-.-,-. . _. <br /> Water Supply: Public'System and name__ .. ..___ Private ❑ <br /> p ❑ ❑ y ❑ --- -- .................. ...... .. --- - --- -- <br /> Character of sail to a depth of 3 feet: Sand Silt Clay N 'Peau❑.i.. Sandy Loom E] Clay Loam <br /> Hardpan E] Adobe ❑ Fill Material.. --- ---.if 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: <br /> (No -septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK .. Liquid Depth._------...........------cp; <br /> [ � Size.__....... -- ------------------- - <br /> Capacity --- ,- --------Type-------------..........Material---------------...---_..No. Compartments-----...---------- .... ! <br /> I .. �' <br /> Distance to nearest: Well.----- ----- ..................Foundation.......... . :_....... ...Prop. Line............................ <br /> �a <br /> LEACHING LINE [ ) No. of Lines --------------- :-:.Len gth­of-each-line.--3-----------------Total <br /> t Length . <br /> i <br /> `D' Box-.........Type Filter Material....... ..... ....Depth Filter Material-- --.-.......-............................._................... <br /> Distance to nearest: Well----------------- - Foundation.....--------------------- .Property Line---------.----.---- <br /> Depth............. Diameter <br /> -...---.-----.-- <br /> SEEPAGE PIT __ <br /> ..:............. Number-..-.....-.."_ -.------------ Rock Filled Yes E] No <br /> ❑ <br /> f 7 ... -- <br /> Water Table Depth..--_...T.;_- - ----------------Rock Size-..------ ---------------•----•----- � <br /> Distance to nearest: Well..._-__...'---- -------- -------------------Foundation................- Prop. Line.........-............ <br /> ._ - <br /> REPAIR/ADDITION (Prev. Sanitcitian Permit#------------- Date---.-------... :..........___.....__..__ <br /> Septic Tank (Specify Requirementsl..- -----.`. . <br /> Disposal Field (Specify Requirements) ..._ --- ..------ . ---•-------.:._ --------------------------------- <br /> --------------------- ........ ..#� 4 __..�r <br /> ... - -- -------------- <br /> {Draw exi ting and required addition on reverse side} <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 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 of -California." <br /> Signed------ = Owner <br /> By............. -" ' .. <br /> ----- �----�--�i -�--- Title............. <br /> _... ..-- =-=------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- - -....."DATE _..-?/!.2 .. <br /> DIVISION OF LAND NUMBER.-- - ---DATE..--.---............ . . . <br /> ADDITIONAL COMMENTS <br /> ------------- ----------------- -...."-....--....._....----......----- ....---....----.... . -----.....------ --•------------ ----------------.-.. ............ --•--...----.... .......... <br /> Final Inspectian,bY: - - Date. ............... . <br /> EH 13 24 �' ��. _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 2,ia» REV. ���e 3M <br />