79-599 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----•----------------------- - 9'. 5 `�, (Complete in Triplicate) Permit No....................... ---------------•--•-- ..-- -- - Date Issued.-.,.'ID .........................----------------- This Permit Expires 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: �y . .CENSUS TRACT..................JOB ADDRESS/LOCATION vv�.f�..-/...-- , ..� .1_.. ^K...- - .. . Owner's Name.- ...-....--rl }}-U. � _ .----;-•---- Phone..�T ....... .......... ...... ` Address........... dt....1 - - ..CityG#i % 4..1f'!� ._.Zip �y,` �f�......... Contractor's Name 1 1J�. --------.-------- .................•------..License ....Phone.Installation will will serve: Residence ❑ Apartment House ❑ Commercial PK Trailer Court ❑ � Motel ❑ Other .......> Number of living units:..--.,--- ------Number of bedrooms.......... Garbage Grinder------------Lot Size,7/1...�..�..�.. Water Supply; Public System and name.. ................... .-.----Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ Hardpan F] • 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 sewers available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size..... 'Y� .�C.' -.........._...---_Liquid Depth._..- Capacity. ..�v_------TypeGr _.Materia 1...."~._.. ..No.'Compartments.a. Distance to nearest: Well.-./��--------- .-.--- ---- ---------F undation..._...... . .....- .. - Prop. Line-----.-.-.--.-..--..--.-..- LEACHING LINE [ ] No. of Lines _�?-_ -------------- Length of each linB ...-�®...�_f_'._. g l Q . ... Tofia! Length _. �--------------------- ----•-- // 'D' Box..l.......Type Filter Material A15vo�aDepth Filter Material ......_l�---- ------------------------__-_--------- Distance to nearest: WeiI..�Q�#!___------..___. Foundation...`J. .......... ......Property Line.- Q _- SEEPAGE PIT [ ] Depth................Diameter---------------.....Number__.,:;_'..:_....—_-------- J, Rock Filled Yes ❑ Nosk Water Table Depth.-------------- _ .......Rock•Size------------------------------------------- Distance ------------------ -Distance to nearest: Well---------------------------, ------------ -.-----.Foundation..- .. .....Prop. Line....... _ . REPAIR/ADDITION (Prev. Sanitation Permit#-....--.---------------- _ ..-- ..........Date.-.----•--------------------------_-.--------) Septic Tank (Specify Requirements)------ ._ ....... . Disposal Field (Specify Requirements).....................-: -------------------------------------------------------------------- . --- .......--- ----• ---------------------------------- ---------------------- -- --------- ------- ------------ - --- - - --------------------------------------------------- ---------•-- .1................ (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 p rformance of the work,for which this permit is issued, I shall not employ any person in such manner as to become subject Wa man's Fompensation laws of California." Signed..... tic ..--------- - :- ----------------- .....Owner By......................... - ....................................Title........------......-- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ..--- ---..DATE ........ f �� .......... DIVISION OF LAND NUMBER...... . .... .. .. ----------- DATE......................... .... ............... .......... ....... ADDITIONAL COMMENTS........................ . . ----------- ....... ...... ................ ...... ............... -----------------............................... -----------------..----.------......-- --------------- ........ ..- - ......... ........ ----------------------•-------------------------- --------------------------------- - ............ - S .. .__........ ---. Final Inspection 9 EH 13 44 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV: 7/76 3M r.