Laserfiche WebLink
+sem <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> i - APPLICATION FOR SANITATION PERMIT <br /> ---------------- Permit No.---- - <br /> (Complete in Triplicate) <br /> " Date Issued-- <br /> --------------------­------------------------------ <br /> ssued___-----_------------------------"---___..__.___._..__ -_ 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 /> .. <br /> JOB ADDRESS/LOCATION �Z ---------CENSUS TRACT-- ------- - <br /> Owner's Name J .r A =---- °lc�--.-hf'[ >G€Iv , ------ - : F ---- -- ----Phone------------ ,.-------------- - <br /> �. <br /> Address �,�= -------------- <br /> - _-- J tY--- _ Phone P t <br /> C <br /> --------Zi _ <br /> Contractor's Name-=-------- '`- r License #_ 3ZgZr _ <br /> -.. <br /> Installation will serve: Residence b, t Apartment House ❑ :Commercial ❑ ;Trailer Court ❑ <br /> •Motel 0-J-Other= ` =_ <br /> "_. <br /> Number of living units:------ ________Number of.bedrooms_____" -J_7___Garbage Grinder------------Lot Size.____.-_._._-_____-- ._-__ ---.---------.------ <br /> •Water Supply: Public System and name '. -- --------------------- 0 - -------------- ---------------------Private r. <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam (Clay Loam 0 <br /> i 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 seeo, ge pit.permitted if public sewer is available within 200 feet,) ; <br /> PACKAGE TREATMENT [ ] °SEPTIC TANK " [ Size / - ---- ---------------------Liquid Depth- 1�_. _ <br /> Capacity _�d TYP? 'n=s.ele.-' Material °` ' No: Compartments , <br /> Distance to nearest: Well__.__.__e_ .a . __�--________Foundation.___tQ_ .____.Prop. Line_.. _-_ '" <br /> - ---------- <br /> LEACHING LINE [ No. of Lines____________ Length of each,line. 8"" "`_._.__.Total Length--------At"4.4_-_/-°i-._:__________ <br /> t <br /> D' Box._;__ __�_ Type Filter Material-_`--_.�,_�_.Depth Filmer Material_- _1--+ ---'t---.--------- ---------=----------------- - - <br /> --- . '----------- -------- <br /> �?O Foundation__ 1 Q--- :__.Property Line.._--r <br /> [ ] <br /> Distance to nearest:Wel! :_ , _.E. .. ,t. ,_. . <br /> SEEPAGE PIT De t_h_ "__Diameter..,____.- umber_- Rock Frilled Yes ❑ No❑ <br /> Water Table De th = - Rock Size <br /> P ------- <br /> t �_ FourJdcition -— --.Pro Line----------------- <br />, Distance to.nearest: ,Well-'-------------- : ----------- -- -- P.t <br /> IA. <br /> REPAIR/ADDITION (Prev. Sonitation Permit#---_----'-=----_------- ----.Date-----'--° -:_: °--------------------- ) <br /> I Septic Tank (Specify Requirements)"-.-.._" -------- -= - ------ -"- ----- ---- <br /> Disposal Field (Specify Requirements) ------------- -----: ------- <br /> ----------------------------------- <br /> 17�'--------------------------------------------------------- <br /> V <br /> --------- :;-' <br /> -------------------: .------------------ <br /> kt: __-_____..____ - <br /> ___. __________________________________________ _ _ ------ ______ _ __-------------------------------------- __ .___.__-_____ <br /> --___- <br /> ------------------------------------------- '.------_----.------- -- "-------- - _ _-_--_------------------:--I-:--------------------------_ <br /> ----------------- _-____..-___-_..____.____` ___-_____...__.._ <br /> "1' a r <br /> {Draw exlsting rind required addition on reverse side) <br /> I hereby certify that I have prepared this'application and th t the.ork 1 will be-done An accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of ,the Son4oaquin Local,:Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "i certify that in the perlo"rmance of'fhe work for which' this"permit is issued, I shall not employ-any person in such manner as x <br /> to become.subject to Workman's Compensation laws of California.'.. R ' <br /> Signed = ----'Owner �e <br /> By( Ti#1e__ ----- - { <br /> - ------------- --------- - - -- -- <br /> a_. w <br /> ` (!f other than owner) <br /> r t ' FOR DEPARTMENT LISE'ONLY- <br /> APPLICATION ACCEPTED BY_ .� - _- DATE._ <br /> DIVISION OF LAND NUMBER.;------------------------------------- ----------------------- - DATE <br /> ADDITIONAL COMMENTS------ --------------------------------=--------------------- ---------------------------------------------- ------------------- --------------- -------- <br /> - <br /> k <br /> _--_ -- . <br /> fir, .. --------- -----------D--a--t-e--.-.Final-Inspection ection b - <br /> EH 13 24 SAN JOAQUI LOCAL HEALTH,DISTRICT' Fss 21677 Rev. 7i�e 3m <br />