Laserfiche WebLink
r Sa 9 <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> I APPLICATION FOR SANITATION PERMIT Permit No "7L_� <br /> ' <br /> --------------------------------------------------------- , <br /> - (CoMplete in Triplicate) -- -- - �- <br /> � —. - ' <br /> Date Issued----- ---- <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 /> T yw1 <br /> ADDRESS/LOCATION, -- r-----��,-- -;=-------- <br /> JOB , .CENSUS-TRACT -F. <br /> Owner's Nome.___Z�&/ -��. - ------ --- ------------ <br /> _f:\ 1 Phoney <br /> = _. <br /> Address.--- � � ---- - -'—off ..` .... itY - <br /> I �.0 '7 /C <br /> . Z1P- <br /> Contractor's Name ---_---- ; = ------ --------------- License #--r ;> / --Phone ; <br /> : , . <br /> InstallationwilC serve: Residence �' Apartment House ❑ Commercial L] YTrailer Court ❑ , <br /> I . .,.__. ' Motel s Other + +• " <br /> � ❑" - -- = r <br /> t Number of living units:__ _-/______Nurriber of. bedroo `___ _Garb,dge Grindea_ Loti Size---------- x � -- -- ---------- <br /> WaI 4 U <br /> ter Supply: Public System and name----=----------- .= __--.-_--.--------i-----------_.- ._--.------,-------------------- ---Private ❑ <br /> Character of soil to a depth of 3 feet: ,Sand ❑ -Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> f Hardpan ❑ ;Adobe F711 Material-_.- _If yes, type----------!_____________ ______ <br /> r [Plot plan, showing size of lot, location oPsysfem in relation to wells, buildings, etc.•must be placed on reverse side.} <br /> i NEW INSTALLATION;— .(No:septic tank or` seepage pit permitted i pu lic sewer is available within 200 feet,} <br /> PACKAGE TREATMENT"[']' SEPTIC TANK [ ] Size----- ------------------------------=--------------- '----Liquid Depth-.------.------;------'- <br /> _- <br /> -r-• Capacity Type----------- -------- ---------------Na. Compartments---=------------------------------ <br /> � <br /> :D.istance'-to.nearest. Well.......... ---- - : Foundation_.-.- --------�-= -----Prop. Line- ---------------------=--� <br /> -_.Len Length of each line_.__ Total'-'Length} <br /> LEACHING LINE_ ...[,] ..No,.of-Lines-- =----- ---------=-------- -- - 9 _ ----_-------------�-:_---. _ ,- -----------------, ------- _- { <br /> " D' Box------------Type Filter Material_------ r__---Depth Filter Material,. :._-- - ----}-----_-__-- -----r--------- <br /> ----------------------------- <br /> -------- <br /> „.. ._ .. - <br /> 3 <br /> - -- operty Line--------- ---------------------� <br /> Distance.to nearest: Well________________ __ ___ _ __Foundation-______.__�-__.____.___ <br /> SEEPAGE PIT [ ] Depth_-- Diameter--------------- ----Number---------_---- ---:---------- Rock Filled Yes ❑ No <br /> : Table.Depth---=--------------=-------------=----------- ------------RockEV <br /> 'Size-; €------------- - ------------ <br /> Water . <br /> -. - y. <br /> } Prop. Line j 1 <br /> Distance"f nearest:-Well-"--------------------------=--------------Foundation--.-----------_-:_-- ---- <br /> REPAIR/AD,ITION (Prev1,Sanitation Permit#____.•-- ---Date----- ) <br /> ------------ <br /> Septic Tank ;(Specify Req i ements)--- } -��' = = - = -=----- ----=---------- ----- - , <br /> Disposal Field (Specify Requirements)----- -- �- --- ------ --- - - T. <br /> �,. ....�� -- <br /> ' `(Draw exis ng and require ad on on Averse side) -� <br /> hreby cerFiFy that I have prepared this,aplication 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 followings j I <br /> " :_ a <br /> "I certify that in the performance of�the work'for;which this permit 6 issued, I shall not employ any person in such manner as <br /> to beco 'e Ujecl o Workm >�s Com ensation laws'rof California.”Signed-- ----- --- --------- <br /> -- -- � caner <br /> - -- ----- ---------- --- ----------- <br /> . <br /> ' r0 <br /> BY ----- r� '�� �1 � Title . <br /> �� ` <br /> (I other than owner}, <br /> l v FOR DEPARTMENT USE ONLY <br /> i ---- <br /> APPLICATION ACCEPTED BY-i---::.°-�_� --------------------- = -- �------------------- --- --•------ DATE.-.--- *��--'-�- --�----- "----------- <br /> DIVISION OF LAND NUMBER . DATE------------ -- '--------._--. -----`----- <br /> t <br /> ADDITIONALCOMMENTS------------ ---- --------- ------------------------ -_-----=------=--------- ----------- --------------,------------------ ------------------ ----------- <br /> 1 ----- ---- <br /> ------------.-- ? -------------=---- <br /> ----------------------------------I----------------------- <br /> ------------€------------- - ------ .,; <br /> --- - ;'_t ------------------------------------------------'--- ---- -------------- ----- <br /> 1 Final Inspectiom-bY -"------ " '��� <br /> D'ate..y_ --�T -- ----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8S 21677 REV. 7176 3M <br />