Laserfiche WebLink
FOR OFFICE: USES FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> lComplete in Triplicate) Permit Date Issued <br /> Issued._c{.���- �7.. <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 /> Cd.: :..:�,._. ,« .. ..........,:,.CENSUS TRACT-----. .. <br /> s ! <br /> JOB ADDRESS/LOCATION-.,-==`.��. �� .............._... <br />'4 Owner's N me - ....��.--•- <br /> I � ����..... .................. ................................................. ---:..............Phone---.....------:-------- ----.......0 <br /> Cit Gr✓ p = ..... - <br /> Address.... _...:...... 6 ----- -------- .......--------- --------._...--...- Y- e4: . ji Zi <br /> Contractor's. Name._. All ----- .�` .f�� <br /> / epc License #.ate. _._J'�.. ..Phone_ �5._r�'� . <br /> Installation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court!El <br /> t otel ❑ Other........................- ------ --- <br /> Number of livingunits:.._ Number of bedrooms-.?.. <br /> Garbage Grinder Size ..._.... ._ <br /> e <br /> Water Supply. Public System and name---q--- ----•-- = };.... --•------------- .. ------------•--- --------Private <br /> Character of'soil to a depth of 3 feet: Sand ❑ Silt❑ t Clay ❑ Peat.0 Sandy Loam ❑ Clo Loam <br /> Hardpan ❑ Adobe ❑ Fill Material . ..-- ....If yes, type--------------------------------- <br /> } <br /> (Plot-plan, showing size of lot, location..'of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTAL;ATION: � - t 1Ze ailable within 200 feet,} <br /> [ ] SEPTIC TANK 1��,.�� !f <br /> (No septic tan or seepage pet' permitted if public sewer 1s av <br /> PACKAGE TREATMi=NT Ca acct .- _ � .----.-T �e ..���.�.�. Material---...........----------�No. Com r�uid Depth..���--.-----....-_.� <br /> y //� .� <br /> 1�,. _�. <br /> T <br /> .� Distance tomearest: Well `.��..-F. ..... Line.,-�E.�..__�....\� <br /> LEACHING LINE 5 ~T 1 T <br /> ( ] No. of Lines - ........:...........L'ength of each line.-- Total Length _.. .. ....--'..--.-----.. <br /> wz P <br /> D' Box_ _. ..-�-Ty e<Frlter`Mater.ial: + Depth Filter Materia.._ _._ ... .- <br /> k gFy- <br /> Distance to nearest:Well..4a�................Foundation--76-.----.....-...Property i ine-- �t�__........... <br /> ----- - . <br /> t r <br /> SEEPAGE PIT, [ ] Depth.....:.........Diameter--------------_ Number----.___-----...._._---------- Rock Filled Yes ❑ No <br /> Water Table DeptO------------------------ - ------- ---....----:.-.Rock Size.............---------- --- -------------------- <br /> Distance to <br /> ---- ------ <br /> Distance'to nearest:Well.................------.....................Foundation.....-..............----I.Prop. Line------------------.------- <br /> REPAIR/ADDITION [Prev. Sanitation Perm1 #="--------------- ----- Date--------------................------.......... <br /> } <br /> t r <br /> Septic Tank {Specify Requirements);........ -------------------------=--•---------- - -- -•--- - ------------............... <br /> Disposal Field [Specify Requirenientsy".-.....--`-- -------------------- <br /> :................. <br /> ! - - 1 s -------------- ------------- -------------- <br /> -- ---------- �,. �_. ---- .......................... - --------------------------- <br /> .............. _ ----------------------------------------------- --------- -- ---- --------- ------ ----------- �.. �.. <br /> ----------------- <br /> (Draw existing and required addition on reverse sideVi <br /> I hereby certify that I ,have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances,I State Laws, and !Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: (tr <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to n s Compensation laws of California.'; <br /> Signed.. .-........ <br /> { <br /> 1 <br /> BY --`-------------------------------------- Title...- ------ --------- ------------------ ---- .................... <br /> (If other than owner) i <br /> OR DEP RTMEN USE ONLY <br /> i APPLICATION ACCEPTED BY........ ... .. ... . -DATE .....- <br /> i DIVISION"CfF`LAND-NUMBER.... . . ._- . >: ._.= :�: .,DATE, ,. ------ - <br /> ADDITIONAL.COMMENTS--------------------- --------------- ------- ..--- -- <br /> - ---- ----- <br /> _ ---------------- --- ------- -------- <br /> . + � ad.. A,_ ' <br /> ............. <br /> - <br /> ................ .. ........................... ---.. .... --._..-.......-.------------ -------------------- <br /> ...._....___. <br /> ------------------- <br /> Final Inspection by:.... ---------------- .Date...'-_#_.- . .......... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV�71776 3M <br />