Laserfiche WebLink
FOR,OFFICE USE. FOR OFFICE USE': <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- --------------------------------------------- Permit.No. �` � <br /> (Complete in Triplicate) <br /> ----------------- ----------- --------- -------------- - -' <br /> w Date Issued_Aa_77,.7.-,,7.b� <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ^ <br /> JOB ADDRESS/LOCATION.. 4_ ----------- ----------- --- ----------------------- ------CENSUS TRACT......=:•-----=------ <br /> Owner's Name " - ----- ---- Phone--- -------- - ---------------------- <br /> '-` 1- -- ----------- --- --- ---------------------- ----------- City - Zip <br /> Address------------ � y y <br /> =------------- - ----- <br /> Contractors Name.4Av#0A4W-!i ,d1 ,03-- License #- - --.�'- -----Phane.44M ,Y?,Th <br /> Installation wills serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------ ----------- <br /> Number of living units:------/--------Number of bedrooms.----;---Garbage Grinder------------Lot Sized4.JCA_A%r#*1 <br /> > ------Private - <br /> Water Supply: Public System and name----- ------------------------------------- --------------------------- ---------- -------------- L <br /> a <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam A Clay Loam ❑ <br /> s Hardpan ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Size__ _, -dj0_--- __of-A.J.-,v--------___Liquid Depth..__,"'-_---.----- <br /> Capacity- "0. --Type------------------- ---Material--------------------------No. Compartments - ----------1P:- -F---� . <br /> d <br /> Distance to nearest: Well--------/--0-i>F- ---------------------Foundation--------- ------- ------.Prop. Line----- --------------- <br /> LEACHING LINE, [ .] - No. of Lines.------- ------------Length of each [ine------------------------------Total Length---------------------------------------- 'I <br /> 'D' Box--:------,--Type Filter Material---------------------Depth Filter Material-------------------------------------------------------------- <br /> t Distance to nearest: Well----------------------------Foundation----------------------------Property Line------------------------------------ <br /> t �♦ - s . <br /> SEE°Pi4GE-R1T� [ 1 Depth-4O-�.-----.-Diameter_JV-AAeB--Number----------------------------- -- Rock Filled Yes.X No❑ <br /> "/ �,? a*?,"6o Water Table Depth---------------------- <br /> ---------------- -------------Rock Size---I-- - ----------------------------------- <br /> Distance <br /> --------------- -- -- - ------- <br /> Distance to nearest; Well-------/_0_0_0----------------------Foundation----__,__ ----._____.Prop, Line_____ "------------------ . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-.-,--- --------------------------------------Date------------------------------------------ --)" <br /> SepticTank (Specify R ---------------=--L------------------=---- ---------------------- ------ ----------------- - --------- <br /> Disposal Field (Specify Requirements)'--,24P--. � <br /> A <br /> �s <br /> H ` <br /> ' (Draw existing and required addition on reverse side) <br /> I hereby certify that I'ha've prepared this application and that theswork..will-be-done inaccordance 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 to Workman's.Compensation laws of, California." y <br /> Signed---- -----Owner <br /> Title-------------------------------- <br /> ------------- <br /> F <br /> = --------------------- <br /> By_ '(If`other:than owner) ; <br /> FOR DEPARTME-Nj USE ONLY <br /> APPLICATION ACCEPTED BY. ------------------DATE.- ' lam <br /> DIVISION OF LAND NUMBER - ------ ------- ° -------------------DATE-------- -------------- <br /> ADDITIONALCOMMENTS--------------------- -------------- - --------='-------- --------------=-`------------------- ------------------ <br /> --------- <br /> ----------- --- <br /> --------------------------- ----- --- ---------------------- <br /> ----------- ----------------- ---- ----------------- -------- <br /> ----------------- <br /> -f- ---- ------------- -- Y <br /> ------------------------------------------------------ <br /> ---- <br /> - - - ---- --- <br /> Final lns ec#ion,b Date------ =-Z---`?g--------- <br /> p Y - = - <br /> F&5 21677 REV. 7/76 3M <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />