Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> m � APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> (Complete------------------ ---------------------- <br /> (Complete in Triplicate) Permit No.? --------------- <br /> Date <br /> -- ----_Date IssuedA/,;7__,_2/29 <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_.._f�-� - •-:---'�----- --- ---- ----- -CENSUS TRACT 1 <br /> _. ,�.rc'O -- L ----------------------------- -- -----------------Phone-_M�/ ` <br /> Address Name...---- --ft 11.Gr�:7- - _. <br /> Phone--- <br /> Owner's _ <br /> J�X`� .. ....` ' Zip.__;-------------- <br /> . <br /> Contr��a tor's Name__' `• License #------ '----- -------- <br /> Instal.lationti-w.il.l„serve:...;.,...... Residence-( J—Apartrrent-House"❑l—Commercial E) Trailer Court ❑ <br /> + �, <br /> ........Motel ❑ Other-.--- ;" <br /> ` f <br /> Number of living units:.___[*...._-------Number.of.bedrooms__3------Garbage Grinde,r._ _Lot;Size f { <br /> Water Supply: Public System and name =----------------------------------- f' ,-..--.-:--------------7-------- ----- ---- - <br /> p ❑ ❑ Y ❑ ❑ <br /> Character of soil to a de -th of 3 feet: Sand Silt Cla ' i Peat Sandy Loam EX Clay Loam ❑ ' <br /> Hardpan ❑ Adobe ❑ Filf�Material--::t---If-yes;type-------------------------------- �r <br /> (Plot plan, showing size of lot, location of system in—,relation to-wells buildings,'-etc must be placed on reverse side.) I <br /> NEW�INSTALLATION: (No'tseptic tank for ge pit ppermitted if public sewer is available wffh'in 260165f) <br /> PACKAGE TREATMENT_ [ ] -8EPTICITANKI N` "; 1'N�,Y\Size�' � __--- -------------- Liquid Depth.-_!.�--_ .___-_,�,. <br /> c''L�. ?RSG" - - i _ <br /> Cap�ic,ity�,� -- Type____-- Material ---- ------------------No. Compartments _ _-- <br /> 4 <br /> Distance nearest: Well_.'/lam_ x_ "" .. foundation fC?___ -------- Prop. Linea ------------ <br /> 11P <br /> LEACHING'LINE;, L'). No..of Lines - g ✓ :--�� - g ----------- --± � <br /> Len th of each line_ d Total Length. <br /> D' Box__ ( Type Filter MateriaL_�/ epth Filter Material.__/ _ -�_________________________________________ <br /> ------ , <br /> rDistance•to riearest: Well_-.-___�^____ -Foundation--- f <br /> ----- -------- - Property Line ` ------------------- <br /> is Depth - Diameter ,. -- _- ._P4 :y L <br /> pert . -- <br /> •SEEPAGE PIT :C ] ❑ ❑ <br /> _.-Number__________________ ____ __ Rock Filled Yes No � <br /> [Water Table Depth------------------------ --------------RockSize:------`---- o- <br /> 1;ADist6nce-.to nearest; Well._._.__ __.Foundation._;_____.__------------_Prop. Line-.--_-- _------__-------------- <br /> REPAIR/ADDITION (Prev.'Sariitation Permit# ' Date'_.__; .._:'_. _ _ <br /> Septic Tank (Specify Requirements) +_- _ - - ---------------------_--------_ _____ _ <br /> Dis osal.Field (Specify �e u�rementsJ- ----- ------------------'-------�------�^------•-- ---Y-------=-' '----------- -------------------- ----------------------- <br /> # <br /> -------------- - --- <br /> p Ip Y G <br /> �+ <br /> �1� # <br /> g; {Draw existing and required addition on reverse sideJ� <br /> I hereby certify.that I have prepared-this-application.-and-that;the-'work-will-be-doneAn-accord once with SanJoaquin County <br /> Ordinances,. State Laws, and Rul`esanditegula#ions of the: Sari Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the.wprk far which this permit is issued, I shall not employ any person in:such manner as <br /> t <br /> to become subject to Workman's Compensation laws of California.„ #_ f <br /> II i E <br /> Signed � 3.�.�---- - -- -- -----Owner. t l <br /> _.._ -------------:Title---------------------- -' - -------�- �----------- ----- <br /> - <br /> (If'&Ker fKan owner) .. .... , __,.,.._,.. <br /> FOR DEPARTMENT`t]'SE ONL•Y�;i S'NJ`�' ! <br /> [,APPLICATION ACCEPTED BY -------- ----------------- -------- --BATES <br /> DIV <br /> F LAND <br /> ADDIITIONOAL OMMENTS�RGw _ , 1� - DATE------------------------------------------------ <br /> - <br /> - .:_ -- --------------------- <br /> --- - ---- - ---- - <br /> � �c <br /> ------------------------------------------------=--------= <br /> - -------- =--------- --- <br /> ------------------------------- <br /> I ----------------------------------------------------------------------------- --------=------- ------------------------------------------------------------ -------------------------------------- --- <br /> - ---- - - ----------- -- - <br /> Final Inspection by - ---------------------------------- <br /> - <br /> ------------------- ----- --- ”-""- flate_.. <br /> Z l <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M <br />