Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------•----------------- Permit No.ZC), 3 <br /> (Complete in Triplicate) <br /> ------------------------- --_}________ _________ __ This Permit Expires 1 Year From Date Issued <br /> Date Issued -�-~-r­`_�v <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County.. Ordinance No. 549 and existing Rules and Regulatio s: <br /> JOB ADDRESS/LOCATION .--- - --------6, ---------------------------- - CENSUS-TRACT r---.--.-----.-�-f---- <br /> Owner's Name ----------E_x -- !------�Phone iT347f Z _ <br /> - --- -- -- - - --- -- - -------------------------------------=-------- - <br /> -- <br /> Address ---- ---- ----- i � -------- -- .... City ''' --------------------p----------------- -- <br /> --- �t---License # - -------- Phone Lt_,�-r <br /> Contractor's Name .- e <br /> - } � . # / <br /> Installation will serve: Residence *partment H se❑ Commercial:❑Trailer court ❑ <br /> { <br /> Motel ❑Other -------------------------------------------- E , <br /> Number of living units _Number of bedrooms ------_--Garbage Grinder _________- `Lot Size -. ------ -------- <br /> Water Supply: Public System and name -__-__________ ________ t - • ti <br /> --------------- ------------------------------.Private <br /> f <br /> Character of soil to a depth of 3 feet: Sand'❑ Sift E] Clay ❑ Peat E] Sandy dloam ❑ Clay Loam; <br /> Hardpan E] Adobe '[] Fill Material -----j----- 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.) t <br /> ;„ _ . , <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer iswailable within 200 feet,] r <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] 5ize__---- ± - ------------- Liquid Depth -.-.-------------------- <br /> -11 <br /> Capacity -------------------- Type -------------------- Material------- <br /> , ----- No. Compartments ---------- ......:....J_(J4 <br /> - <br /> ' <br /> stance to nearest: Well _-_--------__________------------Foundation Prop. Line _-_-_-------_--....._ <br /> LEACHING LINE %::��No. of Lines_ Length of ach li ;___ ---.--_--. Total Length -__-_--_ -. ?___-_ r <br /> 'D' Box ---'--_ Type Filter Material � L__' Depth Filter Material _-- cF ' Q <br /> Distance toPnearest: Well ---_ ?-�---_.Foundation r'Property line --_ ------ . <br /> ..-. t <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Nu 6er -1--------------------------- Rock Filled Yes ❑ No <br /> t � t <br /> Water Table Depth ------------------------------------- ---Rock Size ------------I------------------ <br /> Distance to nearest: Well ------------------------------ ------Foundation --------I----------- Prop. Line ... <br /> t It <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------t__ Date ------:----- ••---------------) r <br /> Septic Tank (Specify Requirements) -------------------- <br /> ___ _ _____ _ -.-�__•.-=--�-- <br /> --- --_Disposa Field (Spe ify Requencs) <br /> ----------- <br /> ---- ----------------- <br /> ------------------- ___ _--------------- <br /> -----------�.--- <br /> (Draw _ <br /> existing and required addition on reverse side) ` <br /> 4 w I hereby certify that I,have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaqui h'Local"Health District. Home owner orilicen- <br /> ... .';sed agents signature certifies the following: y <br /> "I certify t =in.the performance *on <br /> which thrTMENT <br /> it is issued, I shall not employ any person in such manner <br /> a. <br /> } as to'beco a bled tc,WorkTn' nlawornia." <br /> Signed" 1=�.=_ a ----• Title - <br /> - -----------------------------------------BY ' ------------------(lf other than owner) ` <br /> FOR DEP USE)'O_ NLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------- --- `- 1i1_. DATE -- - <br /> BUILDING PERMIT ISSUED --------------------------------- 1 ---DATE <br /> ADDITIONAL COMMENTS --- -------------------------------------------------------------- ----- ---------------------------------------------------------- ------- ---- <br /> - --------------------------------------------------------------- <br /> -------------------------------------------:------- ---- <br /> ---------------- <br /> -------------------- ------------------------------------------------------------ ------------------------------ ----- -------- r ---- - ---•------- <br /> Final Inspection b fL- Date --e _�1 1�J----- <br /> P Y ------------------------------------------ -- <br /> SAN JOAQUIN LOCAL HEALTH DIS CT <br /> E. H. 9 1-'b8 Rev. 5M <br />