Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------------- <br /> (Complete in Triplicate) �p''�_ <br /> Permit <br /> ---------------------------------------- --- ------------ " <br /> s . <br /> Date Issued/.2-�.-�_ff- <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 /> JOB ADDRESS/LOCATION.-_ :?_- - .. - �>------ - i CEN Z`tr44---- <br /> Owner's Name -- - ---- Phone .� <br /> / Z <br /> Address c ��s -� ._- . . ' :City--.-- ���`'------------- <br /> -----Zip--- <br /> F Contractor's Name._ .c --C _- a ----- -----------------------License #. jU_ � _-_--Phone--- ��✓�� <br /> h. <br /> Installation will serve: Residence ❑- Apartment House Cor,�mP,r�ial E] -Trailer Court ❑ i <br /> _..4.._ ► Motel ❑ Other =-------- <br /> s R <br /> Number-of living units:_,__/-:------Number.bf..bedroo- ms.-----------Garbage Grinder------,..__.Lot Size----------------------- ----------------------------- ----- <br /> Water Supply: Public System-and name- --- ---.----- ----- ----- - - -- --------- --- -------------- -.-, Private <br /> ------ <br /> Character of soil to a depth of 3 feet: Sand ❑ 'Silt ❑ ,Clay ❑ m Feat [] Sandy Loam 9�— Clay Loam ❑ <br /> Hardpan ❑ , Adobe❑ Fill Material- If yes, type-----------t___c- ___ <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 tbnk or seepage pit permitted if public sewer is available within 200 feet,] t (� <br /> PACKAGE TREATMENT [ ] '•SEPTIC TANK '(G 4 ►r� _. _:-_Liquid Depth_,_ <br /> CapacityJ4dQ TYpe {'` j_•_ - —:Z ' <br /> / _Material_:.�� r� --_ No.�Compartmeits- -------------- <br /> r C <br /> distance to nearest: Well-= Len th of each line_ Foundation_ _______--------Pro Line_. __.---. <br /> 1 _ <br /> LEACHING LINE . ['�' No. of Lines.:---- - -..- . ` ng ! f �D.� © .i -f-Total Length.f` / <br /> % - <br /> 1 D' Box /`--.---T a Filter Material_.�_'/ <br /> Type - �pth Filter Material---'---------------------- ------------'---------------- <br /> Distance, <br /> ------- -Distance to nearest: Well_ ___ Q________ _____ _ tion..- ' `" �.-----.__.Property Line-- --��_-----_---._____-_ <br /> 15 f Founda <br /> Depth-.fa -.---9 e#aG-? -Number--- ---_--- - - ---- --- Rock Filled Yes 8_N <br /> - <br /> Wafter Table Depth. Rock Siie //�---=Y-���/ ---------------------- <br /> jDistanceito nearest:'-Well_ / Foundation ---- ---------------- Prop. <br /> Line---- ---/ <br /> - - -`--�------ rlC1- _ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__ _____ -------- <br /> -------------------------------------Date-.-_- -------------- <br /> --------------______ <br /> Septic Tank (Specify Requirements)--- ` -- -i- -- ---------------------------------= =r `= s . <br /> :- --- <br /> ------- <br /> Disposal Field (Specify Requirements)----- ------ -----------------------------' <br /> -----;---------------------------------------- - ---------------------------------------------- - <br /> I . <br /> - --------- ---------------------------------- µ ------- <br /> ------------------------------------------------------ <br /> ------------ ---- --- - <br /> ------------------------ -- ---- --------------- <br /> P ----------------------------------`---=-------"`---------------------------------_----_------------..---------------. - --.--.-..-___ <br /> (Draw existing and required addition on reverse sid]•a 7 <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 /> to become subject to Workma Compensation laws of California.".. <br /> Signed_----------- ---- --------------- -=- -------- <br /> x <br /> . . ------- <br /> ------------------ Owner <br /> :: ----BY - <br /> (If other th n`owner] <br /> ' "'FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- C'--- ------------ -'- ------ DATE f <br /> DIVISION OF LAND NUMBER ------DATE--------------- ----------- - ----- <br /> ADDITIONAL COMMENTS-------------------------------- -------- ----------- <br /> - --------------------------------------------------- --- -- - ----------------------------------- <br /> } <br /> ----------------- - <br /> --------------- ------ --------- <br /> l- -------------- <br /> --------------------------------------------------- - - . , - -�-------- <br /> _ _ - - . _. � _Y <br /> - - <br /> --------------- <br /> ----- <br /> ------------- <br /> = - ` --- --� ----------------- <br /> Final Inspection bY==-- - ------------------------------------- ---- ------------------------- <br /> EH <br /> --------- ----EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7/75 3M <br />