Laserfiche WebLink
FOR OFFICE USE: ? FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------ tr aNo.__ �.S~ <br /> F (Complete in Triplicate) Permit __-_.__.._. <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'Ordinanc No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.....-�_L__O°_`-,_ .._----_� --- _---- --- .............CENSUS TRACT------------------------ <br /> z ..._. <br /> Owner s Name. ` - r - = ----=--- Phone. <br /> r - - <br /> Address.-----------= Cit Z� <br /> --- - --- -- Y P-------------------------- <br /> Contractor's Name �� = = License Phone <br /> Installation will serve: ResidenceApartment House Com rcial E Trailer Court E] <br />` y = Motel ❑ Other__ _ :- �o__ liru�! <br /> Number of living units:---__.y____Number of bedrooms-___(------Garbage Grinder__._...------__.Lot-Size:._. _ *__. <br /> i 1 <br /> Water Supply: Public System and'name----------------------------=--=-----=------- -------------------------- ---- -------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt 'Clay Peat Sand oam Clay Loam [ <br /> p ❑ ❑ Y ❑_; ! Y ❑ Y <br /> i P ❑ _ <br /> ,Hardpan Adobe ❑ Fill Material-_.._ -_.If yes, type______#_..__:------:1L...... <br /> (Plot plan, showing-si e-of lot,location of system in elation to wells, buildings,-etc. :must be placed on reverse side.) <br /> NEW INSTALLATION:' (No'. septic tank or seepage pit permitted if publicsewer is available within 200 feet,)' 1, <br /> PACKAGE TREATMENT [ ]' SEPTIC-TANK [ ] - _ Size----------------------_------------ + __----------------Liquid Depth---------------------------- <br /> ---No, <br /> -------------------- --� <br /> Capacity_.___:. TYPe""``-` ---- Material �' .9 <br /> rt`m e�nts <br /> 1 -Eosindatio ... ---- E Pro Line --------------------- <br /> 0 Coom a <br /> 00 <br /> . -.._. . Distance-to-nearest;_W P <br /> LEACHING'LINE; [k �No., of - .: -:--.Length of each line __, __-_ -.-__-_�_ Total?Length _- - d <br /> } t D'4Box_____'------Typ Iter-Material--- 'D f�Fil'ter-Mae I_ _-- -- ----__ -- - -. / <br /> -,•- --------------------------Property`',Hne----- ----------=----•------------ <br /> ----------------- <br /> SEEPAGE PIT [ ] De th_.._ -___...__.Diamet r`f,,Q;.____ -Number_________________ <br /> Distance to nearest: Well_: Foundation-_. <br />{ p :. = k Filled Ye N <br /> Roe - s ❑ ' <br /> Water Table Depth---`------ -----=--------------------------------- -----Rock Size:---------- --- ------------------------------ <br /> Distance tci <br /> ------ ------------------Distance.tonearest: Well--------------------------------------------Foundation----------------"-------'.Prop. Line--------------------------- <br /> REPAIR/ADDITION <br /> -------------------- -_---REPAIR/ADDITION (Prev. Sanitation Permit#----------- <br /> ----------------------- <br /> ------------------Date--------------: ------ `---_ -_.__-} <br /> kSeptic Tank (Specify Requirements)-- _- ------=------------------------------------------------ -----------------=--------------------- ------- -------- --------------- --- ------------ <br />` Disposal. Field (Specify R uirements):_ <br /> ------------- ------------ - ---�-- ---- --- ---. - --- ----- <br /> - <br /> G�" --- -- --- J <br /> Draw existing and're uired addition'on revel's sid✓ e <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: 3 <br /> "I certify that in 'the performance of`the work for which this permit is issued, 1 shall not employ any person in such mariner as <br /> i to become subject to .Workman's Compensation' laws of.California." , <br /> Signed- --- - --------------------------------- = --=------- ---- Owner <br /> B 3 -- Title r f ---------- ------------------ -- <br /> _ _ <br /> Y --------------=------------------------------ = - - <br /> k <br /> (If other than owner) <br /> l R DEP ENT USE ONLY. ] <br /> APPLICATION ACCEPTED. BY----- = -Cj +=--=-- ------ --- -----------------------------------------------------=------DATE/�" --- <br /> I DIVISION OF LAND NUMBER--------------=------ --DATE-`------------------------ - -- <br /> ------ .- <br /> ADDITIONALCOMMENTS-------------------- ------- ------------:----------------------- --.------= - ------------------------------------------------------- ----------- <br /> ------------------------------------------------____----___----------------------,__..___------ __:----_--------_------ <br /> ---------- _.__.._._..__S__________..------------------- <br /> _ _ ------------------------------------ <br /> _ _ ___________________________ _ ---------------- <br /> - <br /> _______ _____-. <br /> 2-a» rev. <br /> Final Inspection by: _�'" --- - ------ ---_Date_��-:'---------------------------------------- <br /> EH <br /> -- - - "--- -------- . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 7/76 3m <br />