78-1116 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: ;v FOR OFFICE USE: i APPLICATION FOR SANITATION PERMIT -----•---------------------- -- --------- - ----- (Complete in Triplicate) Permit ••-•-••••••- -- � --- �- ------------------ �+ This Permit Expires 1 Year From Date Issued -*Date Issued.J.;". 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; 7 JOB ADDRESS/LOCATIO ®fes CENSUS TRACT ........ .................. Owner's Name ._......- . �n......'r -----Phone----------- =---- - Address .`3 ......... ' ...--- ...... .. City '� Zip iN .---- .License # 7_ ,/ 'Contractor's Name ...... Phone - Installation J� Y will serve: Residence Apartment House ❑ Commercial ❑ . Trailer Court ❑ ii Motel ❑ Other...'...-..........--- - ------- ------ Numberi of living units:............ -Nu rri6er of bedrooms.._.._.:�..Garbage Grind erLx 19------Lot Size . -. ... . 7l"'� � .. Water Supply: Public System and name--- ------ ------..Private Character of soil•-to-a--depth-of-3 feet:A and-�. 5i•It; - day ❑ Peat ❑ -Sandy Loam ❑ Clay-Loam_❑.-..,,....._..��__.�__,. . Hardpan ❑ Adobe Q 11 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 [ ] Size-------- --------------------------------------------------Liquid Depth..............................5:� Capacity- II ... -----TYPe.-=----- MateriaI------------------------_No. Compartments_...................... '- ` Distance to nearest. Well------------- ......-.. .....Foundation.....-.... . ..........._.Prop. Line........-----'-.-- LEACHING LINE [ ] No. of Lines.11.......................... Length of each line;+---------------:::__-:�-- -^-Total Length --------------------------------------- D' ....-----------------------.-----.- --D' Box--- .--..I..Type Filter Material-..- ........Depth Filter Material---------- ....................................................... Distance ..Foundation.................... ........Property Line.....----.---- ---------------- SEEPAGE PIT [ ] Depth._...-.--. ' --Diameter....................Number.:------------------------ ........ Rdck Filled Yes ❑ No ❑ Water Tablei�Depth-------------------- ----- ..Rock Size..._'_._........ Distance to n�a est;: Well...........................................Fa ndation................._.......Prop. Line.-_. :::... REPAIR/ADDITION (Prev, Sanitation Permit .......................... ___.......Date.----------------................._.........._] � I Septic Tank [Specify Requirements].--.-:----...... - a.�..... .......- ` - ----_--------= . ......... { , p Disposal Field (Specify Requirements] °....... �� 9`i!iC ..... - �!' �.-C.. - -''.................. ` L/` IJ. ........... -----•-- ....... ----- ..... — - ..... ---------------- -- ------- :. ---.........-- ... ---------------------------- ........ -. - ._ _- • _ _._. _ t-Draw-existing and-required addition on-reverse.side).-.,- .— � I hereby certify that I have prepared 6this application and that the work will be done in accordance with San Joaquin County i Ordinances, State Laws, and Rules!kand Regulations of the San Joaquin`Local Health District. Home owner or licensed agents signature certifies the following: it t ; "I certify that in the performance of 4he work for which this permit is issued, I shall not empfo.y.-any person in such manner as to become subject to Workman's Compensation laws of California." �I Si ned..-_. i 9 n - -Owner BYTitle f - (If other than�wner] /,/TOlVDEPARTf#tNT USE ONLY APPLICATION ACCEPTED BY-.-___... DATE _-......I --_.. ..7. ....--- DIVISION OF LAND NUMBER..............' �. DATE-... ----- --- --- -------------- ..................DATE...16 x4 �� f ADDITIONALCOMMENTS..................]�..........-..... ----- - ---- --- •------ --------...-----•-----------...---....-------- ------------------------------------ iI . - ----------- -------------------------- - .............. ........... -------------...-------------------------------------------------------- ----------- -------------- ..........----------- ---------------- - :I ---------•-------------------------------------- inal Insaechon by ... - ------ � ------------------------------ --------- ----Date CH 13 2' y��SAN JOAQUIN LOCAL HEALTH DISTRICT ras 2W7 REV. i/