Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------- ermit No.-7,7- -577G) 0 (Complete.in jriplicatel.� <br /> 1 <br /> ` Date Issued----------------- -- <br /> --------------------------------------------------- ----- This Permit Expires I 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 Orclinanc No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT ON....._____.,-_ �__, �i' <br /> 5 ------- -- �- - - ----------- -------------------------.CENSUS TRACT ------------------------------ <br /> - 7; F'4 <br /> Owner's Name ------------------- " Phone 7.. <br /> -- _ <br /> Address---.- t - ---------- �2- -------------- ---- ---- * City. _ 1 ----------------zip--/,S_' <br /> Contractor's Name_____ ____ ___ ____ ___ _.______-__License # is - Phone---V4-5 _�-_-. <br /> Instal latn will serve: Residence [Apartment House.❑ Commercial E]F Trailer Court ❑ <br /> Motel ❑ Other-------------------w---- -----{ ' <br /> Number of living units:------`----Number of bedrooms- _--Garbage Grinder__„_ .,.__Lot Size----- <br /> -- - -------------._.______._____._� <br /> =. ...- <br /> Water Supply; Public System and name_________________________ __--------------------------- <br /> -- -----------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay /Peat❑ Sandy Loam Clay Loam ❑ <br /> 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,publ' sewer is available within 200 feet,) . <br /> i <br /> J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [� Siz ._L� -Liquid Depth.--- -K--------------- <br /> �"�..." - ------------------------------ <br /> CapacitY ---___TYPe _r1t <br /> .Material-CC. --------No. Compartments------s ------------ <br /> Distance to near!!!: WelLI4?tV __:.____.-,_Foundation._✓6S_r --__. <br /> Prop. Line - ---------- <br /> LEACHING LINE ! ' <br /> [y�Na. of Lines_.__'________.____.__ Length of,�each line'.: x __..Total Length._____,�_ _ _________________ <br /> D' Box_.. __-__Type Filter MateriaLS!(/Illel� epth Filter Material____-��_____------------------------------------------- <br /> f <br /> �/ r <br /> ,o Distance to nearest: Well--.-� ______________Foundation_-/ Property Line________ _------- <br /> - � -13L <br /> -. - <br /> ,SlEPA15Z- T [t+ Depth__/4--____Diamete_ �___. ..O-.Number-------.�--.-__---------- Rock Filled Yes ®---No ❑ <br /> Water Table Depth.--- ------ ------------------------------------Rock Size- --K-3--- ------------------------ <br /> Distance to nearest: Well--- .5 ---------------------------Foundation.__-�76--- --- --- Line_ f__ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------- Date--------------------------- -------.._.__._.__)I <br /> SepticTank (Specify Requirements)---------- ---------------------------------------------------------- --------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements)------- -- ------------------------------- ----------------------------------------- ----- ----- ------------------------------ <br /> ------------------------------------------ ---- ------------------ ---- ---------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 u lett, to W man' Compensation laws of California." <br /> Signed :i - �. -�------ --------------------------------- Owner <br /> BY + f �" Title--------------�--------------------- ----- <br /> ------------- <br /> -- -- --------------------- <br /> (If other than o ner) <br /> Ae FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ------------- -- ----- -------- ---- <br /> ------ ------------------------------------DATE.--J-�---+--- ---- - 7-------- - ------ <br /> DIVISIONOF LAND NUMBER------------------------------ ------------------------------------------------.----DATE------------ ----- ---- ------ --------------- <br /> ADDITIONALCOMMENTS------------------------------------ ----------- ------------------------------------------------------------- ----- --------- ------- ----- --- --- <br /> -------------------------- <br /> - - <br /> ------------------------------------------------------------- <br /> -­----------------------- - -------------- - ----------------------------------------------------------------- ----------------------------------------------------- -------------------------- <br /> ---------------- --------------------- <br /> - - ---------------- ----------------------- <br /> Final Inspection by:.----- - Date. -� <br /> ------------------------------------------- ----------------------- --- <br /> - --- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />