Laserfiche WebLink
FOR OFFICE USE: <br /> FOR lCE USE: <br /> V�dAPPLICATION FOR SANITATION PER <br /> .......................................... ........... <br /> (Complete in Triplicate) <br /> Date Isued-- ;7� <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> W <br /> Application is hereby made to.the SanlJoaquin Local Health District for a permit to construct and i stall 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 .r'-.......CENSUS TRACT-------------•---- -- - <br /> Owner's Name................ ��' n c. "Lr ...`.......-- C1!1:f.3_.... ---=--/ Phone �3_ r. 5�4 g ...._.. <br /> Address - a'� 7 �. ... f..x_Ta" - - <br /> ---------Cit '. L.°.�.. Zip r <br /> Contractor's Name............ �' ... . ---...---- --..License ----------------- Phone------------------•------------ <br /> Installation will serve:-'-- —x Residence E] -- Apartment House❑ Commercial [] ---Trailer-Court 0 <br /> Motel ❑ Other'.....t,.&:a _�j... ec- <br /> crr.e-..'- <br /> Number of living units:..._...,5�___Number of bedrooms.......�.'Garbage Grinder----------..Lot Size--------- _.:S ._ - <br /> ...................... <br /> Waters Supply: Public System and name------- --------- ----- - --------- ......----------...-------•--••-•------•---------- Private (� <br /> I Character of soil #a a depth of­3 feet: S Sand KSilt E] Clay ❑ Peat[ r Sandy Loam ❑� Clay Lo�jm El y <br /> Hardpan ❑Adobe`❑' Fill Material + -.rif Yes, type... _--- <br /> (Plot plan, showing size of.lot, location ofsystemin 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 /> Is 4 <br /> PACKAGE.TREATMENT , [ ] SEPTIC TANK j j Size............ --------------------------------------------Liquid Depth .......... ..... <br /> Capacity".`.....;._----------Type--- .---- Material --- .-----:No. Compartments ...........'............... i t <br /> Distance to nearest: Well------------------------------------- -----Foundation-^- -I-- ...... ._....Prop. Line_-..........-........----•- V) <br /> LINE [ ] No. of Lines - ----=--------------------Length of each line-------------------- <br /> Total Length .....- - <br /> LEACHING z _ � .� <br /> D' Box-...........Type Filter Material........ . ......Depth Filter Material ....--- -----. <br /> Distance to nearest: Well------------- ------- --- . Foundation------------------------- - Property Line------------_ ------- --------._... <br /> SEEPAGE PIT [ ] Depth............ ...Diameter.---------------....Number------------------- ------------ Rock Filled Yes ❑ No ❑ <br /> tWater Table-Depth._..----------••-----`--------- --- -------------------Rock Size-----....... ........................... <br /> 'Distance to nearest: Well-------•------------------------ ---------- Foundation---................'_....-.Prop) Line------------- - ---------- <br /> S <br /> t REPAIR/ADDITION (Prev.5''Sanitation Permit <br /> , #-----------------------an _ --:.-,.-f ---�--.-�+r Dir'.a_.r n•-----.... ------- <br /> Septic Tank (SpecifyRequirements) ----------------------- .................. <br /> ...... -- <br /> �- <br /> --- ------------------- <br /> ----------- <br /> ----- ----._ .. <br /> ...- --------------- -- <br /> ------ <br /> ------- <br /> Disposal Field (Specify Requirements i <br /> j............. <br /> .......................•. .......... ' ------------------- :.I <br /> F(Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this dpplication and that the work will be done in accdr once with San Joaquiin County <br /> Ordinances, State Law's, and Rules' `and, Regulations of the San Joaquin Local Health Distri' Homeowner or licensed agents <br /> signature certifies the following: <br /> ' k <br /> "I certify that in the performa ce of"the work far which this permit is issued, I shall not <br /> plo any person in such manner as <br /> to become ject ork ns Compensation laws of California." <br /> - --_ �. . <br /> i ned - '�Ctwn�r <br /> Y-------- <br /> •----------------------------------- --------- ---- •-----.._.-._..--------- =----- <br /> Titl ----------- - ------- e ............ <br /> (if other than owner) <br /> { FOR DEP R M>E:NT O LY <br /> 1 ' <br /> APPLICATION ACCEPTED BY- -- _.... . --- ----- --= ----- - D E <br /> DIVISION OF LAND NUMBER .---------..F....._. DA <br /> ADDITIONAL COMMENTS-------- ---- - _ --- ---------------._.._.....-- -......._..... <br /> ----•------ - ----------------•- . ------- ---- ---• -- -- -------- <br /> -•-------------------------------- <br /> k ----------------------7. <br /> s <br /> r Final-lnspecilon b - _ ---- ----Dae ...- --- . <br /> Y :. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2167 EV. 7/76 3M <br />