Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR'SANITATION PERMIT <br /> -----------------�......................... �------ Permit <br /> {Complete in Triplicate) <br /> ---- --------- >- -... .. Date Issue&—��_.7 <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 Co ty Ordinance No.549 and existing Rules and Regulations: <br /> Co <br /> JOB ADDRESS/LOC <br /> ,,AT,!PN._� :1�-- - :. _- � u;.dsr .> .-�.L4''-�-�'rea-CENSUS TRACT................................. <br /> Owner's Name. ✓� ' L°A�'... �..... sm rd _ ..ice..... . .............•-------...Phone..........................__...... <br /> 1 Q <br /> -- ._ �-- <br /> Address City ----•--- ----------------- <br /> -------- <br /> ---Phone------------------------:--------- <br /> Contractor <br /> --•-------Phone--------------------Contractor s Name......-- C --- License # <br /> Installation will serve: Residence( Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----- ...... ............................. <br /> Number of living units:- ---l..........Number of bedrooms...-.2_...Garbage Grinder------------Lot:Size.. ZZ-1c,�:-�.��------------------ <br /> Water Supply: Public System and name------_ --- ---- ------ ------ ------- -------r -------------- -- ---- ----------------------------- Private <br /> Ei <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 /> (Plot plan, showing size of tot, 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 /> ..--. -.-- <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 /> 'D' Box............Type Filter Material....................Depth Filter Material.........................-.._-----.-------.-.---_--------.--.- <br /> Distance to nearest: Well------------------------....Foundation........... ----.----.----Property Line-------------------.-.--.-.-.----. <br /> SEEPAGE PIT [ ) Depth................Diameter............------._Number--------------------------_--- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth--------------------------------------------------- _.Rock Size................... ---------------- --------- <br /> Distance to nearest: Well.......-----------------------------------.Foundation----.----.--- --------- Prop. Line------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date..------.----.----... -............------------) <br /> Septic Tank (Specify Requirements-.--------- ------------------------------------- ....... --------------------- ------ ------ ......... <br /> Dispoa-jFie1,dSpedfyRe uirements).. ,c - -------------------- --------=------ ---------•----q <br /> �' I - -fit.h --_z- ... -.- - r = �, P� �t �. . <br /> ----- <br /> ------------------­­------------•- -------- ------------- -•------- ------ -------------------------------------------- .........._.............. ...... <br /> (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 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 Workman's Compensation laws of .California." <br /> Signed-- -- -- ------------ ------- ------ f Owner <br /> <( ....... <br /> BY ------------------------------------ .. . ---...---....----- == <br /> (If other than owner) Title <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. ----..... ' ..-----•--=-----=---------------------------- DATE...) __ .-..Z - -------------------- <br /> DIVISION OF LAND NUMBER-------------__------------ --------- DATE.----- ----------- -------------------- <br /> ADDITIONAL COMMENTS........... . . ........... ------------------ ---------------------------- ---- -- ----- .........................- - - _------ <br /> --------------- --- - --------- -------- •---------------- --- - ---------------------------------------------------------- - -------- ------------- ....... ..........- ....------------- <br /> ------------------------------------ ... ... ------------------------------- --- ------------------------------------------ - ...... --------------- ------- ------........,.. <br /> --•--------------------------------------- - <br /> Final Inspection by:.-------- :'. -----------------------------Date ��- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV.7/76 3M <br />