Laserfiche WebLink
"t FOR OFFICE USE: M FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT r <br /> Permit <br /> (Complete in Triplicate) <br /> -------------------------------------------------------- <br /> Date Issued -� <br /> - <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 Cou Ordinance No. 549 and existing Rules and Regulations: <br /> �� 4 ..CENSUS TRACT _ : <br /> --. .. ...... <br /> JOB ADDRESS/LOCATION--- ..... ..... ...�. �� <br /> —ef <br /> Owner's Name --- .... .--- ---- <br /> r � - ---------------- ------- Phones, <br /> - ,-- :--- -3--- <br /> ---- .... <br /> aCitY Zip- -Address.... _ `' - <br /> Contractor's Name..... - ..Phone.d - -- - #-3431. <br /> Installation will serve: Residence �Aportment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------ --- - - ------------------------ <br /> Number of living units:....-......Number of bedrooms-.-...Y. Garbage Grinder------------Lot Size....... ----.............. <br /> Water Supply: Public System and name-- ------------ - ------------------- -- -------------------------------------------- . . .............. --------------PrivateX <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeFill 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 ------------------------------- Liquid Depth.--------------_ - ----- <br /> Capacity _. - - -----Type------------- ---------Material--------------------- ---No. Compartments....---• ---------------.....-----•N <br /> i` Distance to nearest: Well------------------- ------Foundation----- ... . ..._ ........Prop. Line ---..N <br /> LEACHING LINE [ ] No. of Lines ...........................Length of each line.-.------------------- ------Total Length ... ............................--...... <br /> C1� <br /> 'D' Box..... ..- - Type Filter Material...--- .....Depth Filter Material-- ----------------..----.--------------....---.................. <br /> Distance to nearest: Well----------- --.-----.Foundation------------------------- -Property Line--.-.-----;--- ------ ............ <br /> SEEPAGE PIT { j Depth----------------Diameter-------------.. - -- Number...----------------------------- Rock Filled Yes ❑ No ❑ <br /> i Water Table Depth---------------___.....................................Rock Size----- -- ... . ..... ------------------- <br /> I <br /> Distance to nearest: Well.----------- - .......... ------Foundation...... ...................Prop. Line.............___....... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------_----- Date.......•--...------------......--------- ------1 <br /> I <br /> Septic Tank (Specify Requirements)._......_--.-------- .. .0- ..-- .......... . ........ <br /> A <br /> Disposal Field (Specify Requirements)_.+C�� /. ®. ... '✓�'..... -� / c - <br /> i ---------- ----------- ----------------------------------------------------------- --------------------------- <br /> (Draw existing and required addition on reverse side) <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, 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 /> r to become subjec"o Workman's Compensation laws of California." <br /> Signed.................. <br /> ° Owner <br /> r - ------ __ --- --- <br /> . <br /> ' BY--------------•- - __ ..... .. Title.._.....-----....--------------- ---- �- <br /> (If other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------ ----- --------......--....- <br /> n.... DATE --- --------- <br /> DIVISION OF LAND NUMBER.... . ........................DATE.---------- - ------....------ -------------- - <br /> ADDITIONAL COMMENTS .----...-- ---------- ..---- -- .......... <br /> - ------------------- ................... <br /> i <br /> ------------------- ....... ------- --- ---- ------•----- ----•---------------- <br /> ------------------------------------- ----- - ----- <br /> Final Inspection b ���� <br /> Y:_--------------------- <br /> -- - - -- ------ --------- --Date... -.------------- - ... --. ......� <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 2Ac> REV. 7/76 3M <br />