Laserfiche WebLink
FOR OFFICE USE: / FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT t <br /> -" --------------- ; --- Permit NoT =�f <br /> (Complete in 76plicate) <br /> -..-----•-------------------.......... ---- Date Issued./".2.-"1#778' <br /> ••-,",••,".--,•"..--.."-"""................................... This Permit Expires 1 Year from Date Issued 1 ; <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 /> CENSUS TRACT.. <br /> "----- *-----.JOB ADDRESS/LOCATION....:- ---- ---- ---------" r <br /> Phone <br /> Owner's Name.--- - C .... zip <br /> -�----'-.,----.-_. <br /> -"-""-" -"""-- <br /> ' <br /> Address... --------- <br /> --- -- ........ ./. "-- City Phone <br /> Contractor's Name......""" ..... ..... QLicense <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer.Court`❑ <br /> Motel ❑ Other-. ------- """-""---- <br /> Number of living units; ".""--Number of bedrooms . Garbage Grinder- t—OAot Size--_"...�� <br /> Water Supply: Public System and name-------- -" /;-- <br /> --.---------Private E]------ - ---" -------------- •------.... ..... ----.". -----•- <br /> Character of soil to a depth of 3 feet: Sand ❑ Sil Clay ❑ Peat ❑ Sandy Loam ❑ Clay. Loam El <br /> 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> Cr <br /> PACKAGE TREATMENT [ } SEPTIC TANK [ } Size.......---------------------4----- ---" .........Liquid Depth-------------------------- <br /> - <br /> Capacity---------- - ------Type----- ......_Mate,rial........ ... No. Compartments <br /> Distance to nearest: Well------------"---""---.. .-. ..-------Foundation---------- <br /> --. Prop. Line--- <br /> LEACHING LINE [ ] No. of Lines ------'--------------------Length of each line.. _--.... ""--"...._. Total Length -- ---------- --------�; <br /> `D'.Box".........-.Tyke Filter Material.. Depth Filter Material-"-----------------.......-------------- ----"------ ---------I <br /> Distance.to nearest: Well--------------- ----------.Foundation.----- •--- Property Line.-----"-- """-.-""- C_ <br /> SEEPAGE PIT [ ] Depth.-."-._...... .Diameter--------------------Number--_-------- ----------------- Rock Filled Yes ❑ No ❑-n <br /> Water Table Depth--------------------------- -"------• ----"Rock Size - " ......... ------- ------ <br /> Distance to nearest: Well ._.-.-.".--"-."_....-_-- <br /> Foundation----"----- ".."".--". Prop. Line..--- ...-- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------"-- -----..... te31�1 _--•---•------"-------- "--- ) <br /> Septic Tank (Specify Requirements).-.. - -- -----"""L `�--- <br /> Disposal Field {Sp cif) Requirements.. ----- �` ---- ""--""" -------" " <br /> ---- - <br /> .r"i / 'cZ....... . ... -- ._.. ------ ... . ........ ----- - <br /> E -_.... ----"-------" -�__---.----"_"-"•---"--" <br /> ----""------"" "---"-- <br /> (Draw existing and required,oddition on reverse side) <br /> I hereby certify that 1 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: r <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 /> to become sub' ;ZiWo�an' Compensation laws of California." - <br /> Signed-------- _ �GG�QOO �4 " .. .. ....1. Owner <br /> .Title----- - � .......... -" - <br /> By...--- -- - --------- . - .:.-.-"":=-----"--- ." <br /> {If other than owner) <br /> fOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__-- --- - <br /> - . ----.DATE -- �a ......... .".....- "-- - <br /> } "_.DATE............... ....... ... . --......... --- <br /> DIVISION OF LAND NUMBER' ... ---- ----- <br /> ADDITIONAL COMMENTS --.......... <br /> ....... ... . . . ............ ......... <br /> .............. ...... . ---- ---. --.. --------------------------------- -- <br /> _ _ <br /> - -- ------- --Date_..-- - . .....-- -- <br /> Final Inspeci•ion b ..-- -•-- - -- ------ ------- ---•- <br /> y° � """ - - ---- "- F&S 21677 REV. 7/16 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />