Laserfiche WebLink
USE; OFFICE: USE: <br /> FOR OFFICE U51 <br /> APPLICATION FOR SANITATION PERMIT I <br /> ....... ------ ---- Permit No - <br /> - <br /> - (Complete in Triplicate) <br /> Date Essued�:d�:-? . <br /> .........................................I`'....... ........ This Permit Expires 1 Year From Date Issued <br /> IM <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. I <br /> This application is made i±1 compliance with County Ordinance No. 5 9 and existing Rules and Regulations: <br /> 6 101 <br /> �l SUS TRACT.......... ....... ............ADDRESS/LOCATION ..... /.. ... ------ ------ <br /> Owner's Name...... ----- - --------••-..............------ •-......Phone...._.------------ .......... <br /> Address -� ---- - -----------_-City -------------------- <br /> .------- <br /> ---.- -- ZIP------------- ------ <br /> - ----- <br /> 0k <br /> �- - ft t . <br /> �#_)_�pc1 / . ! -q <br /> Contractor's Name...... . -- ._.._. License Phone. <br /> Installation will serve: Residence 1�1 Apartment-House ❑ Commercial ❑ Trailer Court ❑ <br /> `` Motel ❑ OfHer ------ -_.v- - ---------------------- <br /> Number of living units:....l�.f:--------Number of bedrooms..-.....Garbage Grinder--------....Lot Size---- --------------- " - -- <br /> Water Supply: Public System and name...- .................. ._....... . ---------------------Private ' <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material-- ----..,..If yes, type_._.._-...___.-- ...... <br /> .i. <br /> Mot 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 /> PACKAGE TREATMENT [ �] SEPTIC TANK [ ] Size ------- --- ----------------------- --------------------Liquid Depth-----------_------- <br /> Capacity <br /> --------_-------Capacity......................Type---------------- - ...Material-------- --------•- ---No. Compartments....--= <br /> Distance to nearest: Well---------------------------- --------------Foundation-----..... . .............Prop. Line-------------- .......... <br /> LEACHING LINE [ ] No. of Lines.............. -..__ .--.- Length of each line..--:-------------------------- Total Length .. ....-_------------------------- <br /> [J' Sox-- :':Type Filter Material,_.""--...::..'.._...Depth Filter Material-------------------"------ ------------. _------------- <br /> . 4 <br /> Distance to nearest. Well--------------------- ------Foundation---------------- -_._Property Line...------.--_ _--------.-.----- <br /> �l � 4 <br /> SEEPAGE PIT [ ] Depth.......... ... .Diameter..-.----------- .---Number_...,_°_ --------------------- Rock Filled Yes ❑ No <br /> x <br /> Water Table Depth-------- ...... ---- ............Rock Size----------- ----- -------.------------------ <br /> Distance <br /> -..----- -...._Distance to nearest: Well................ ------Foundation.. ..............Prop. Line....--- ------- -- ---- <br /> i <br /> REPAIR/ADDITION (Prev. Sanitation Permit#......-----=----------------------- ---------------Date--------:................ ............... <br /> Septic Tank (Specify Requirements)--- ------ --------- /�-- <br /> ------- -- -- <br /> Disposal Field (Specify Require ents)___.-._.... .- f '.I....--- - --- L - - <br /> --------- -- - ..... <br /> ---------- - ----------- . . .....------.......... ----.-.... ------... <br /> J (Draw existing and required addition on reverse side) <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 falllowing: <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 Workman's Compensatioan laws of California." <br /> Signed....... ....-11-:----- . Owner <br /> By..__...... ... Title <br /> .---- -. .............. ......... <br /> If ocher than owner) <br /> 1 � <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEDh BY7T <br /> ............................ <br /> DIVISION OF LAND NUMPER...............---------- -------------------- .....DATE............ - ------------ .. <br /> ADDITIONAL COMMENTS... ----- ---- ------- ------- ............ <br /> ------------- ------ -- ------- ..... ------------------------•---------------------- <br /> M <br /> --------- -------- <br /> - <br /> ---- <br /> ------------------------------•--------I------ - -- ------------ --..... <br /> Date <br /> ------- - _Final lnspecnon b � <br /> F85 21677 REV, 7/76 3M <br /> EK 13 24 /// SAN JOAQUIN LOCAL HEALTH DISTRICT <br />