Laserfiche WebLink
FOR OFFICE USE: kAPPLICATION FOR SANITATION PERMIT FOR OFFICE SE: <br /> --- ............. � ;_.•� Permit No---------------! `' <br /> --- - <br /> (Complete in Triplicate) <br /> ------------------------- ------ --------------- v <br /> Date Issued.-_�-J6:.:2�V� <br /> -------------------- -- ......_._....__.__.---.._ This Permit Expires I Year From Date Issuer! <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and,install the work herein described. <br /> i This application is made in compliance with Count Q dinance No. 549 nd existing Rules an Regulations: <br /> 1 ' <br /> aB ADDRESS/LOC ...---. .- ---•- -.q -- CENSUS TRACT.....--•-----•................. <br /> -------- •---------•------- <br /> Owner's Name..: Phone.---------•----------------- --------- <br /> )dress............. C3.c - <br /> I . ...- ...... -_...City _ Zip <br /> __ <br /> r <br /> Contractor's Name. -.................. ............ ' -- ---.License <br /> stallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.... ------- ------ <br /> Number of living units:_:___f._.-------Number of bedrooms_---c�;W._Garbage Grinder------------Lot Size--------- .................... <br /> Fater Supply: Public System and name-- ------ ------------------ --- _..... ' ' -.... ---------------- ------------•---- -------- •--•--Private <br /> Lnoracter 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 /> f plan, showing siof lo <br /> ze t, location of sys#em in relation to wells, buildings, etc. must be placed on reverse side.) <br /> -_o <br /> NEW INSTALLATION: No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) C <br /> FIKAGE TREATMENT SEPTIC TANK ___.._.___-Liquid Depth------------- <br /> � C [ ) [ ) Size....._ '-- ---------------------------- <br /> Capacity_ --T e............... .....Material__ -----------------------No. Compartments-----_-------- <br /> Distance to nearest: Well---------------------..........--------------Foundation--------:. . ........Prop. Line-._......... <br /> .-.------._-.-_ <br /> I, ACHING LINE [•] No. of._Lines -------------.------------.Length of each line....________________------_-Total Length i.-.-------- <br /> I 'D' Box............Type Filter Material-------- ----- --- Depth Filter Material-----------------------------------------.................... <br /> -- <br /> f , Distance,to nearest: Well------------------------------------------ Foundation------------.-_- -_--Property Line------------------.-.-- - <br /> SrEPAGE PIT { ] Depth.... Diameter--- -_....._..Number______________________________ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth........................... ........ -------------- .....Rock Size----------......._------- •-•--•-------------- <br /> s Distance to nearest: Well-------------------------------------------Foundation_..-.-.---------.:_.._..-.Prop. Line----- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------- ----- ---------------Date---------------------.- -------.-_-----.------) <br /> ' ptic Tonle (Specify Requirements).. ...... <br /> - -------- <br /> Disposal Field (Specify Requirements).. . . . ... .. ..: . .. :------ <br /> �- ---- --- <br /> -- --- --- - ---- -- - <br /> --------------­------------- ------ --------------- -- ------------------- -- <br /> �- ---------------------- <br /> (Draw existing andr'equired addition on reverse side) <br /> 1`-iereby certify that I have prepared this application and'that the work will be done in accordance with Sane Joaquin County <br /> f dinances, State taws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> 5, <br /> signature certifies the following: <br /> 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 /> i become subie Workma Com ensation laws of California." <br /> a <br /> Signed. 02 �. _ .........Owner <br /> Title. ... ...................... <br /> ------------------ - -------------._...----•----• .. <br /> (If other than owner) <br /> EPART ENT USE ONLY <br /> 'PLICATION ACCEPTED BY... -- ......-DATE .... .. ....... ...... <br /> DIVISIONOF LAND NUMBER---------- ---- ----------------------------- -------------- ----- ---------------------------------- -" DATE.-------- ----- .........-- " <br /> Af)DITIONAL COMMENTS ----------------.. ---- --------------- ------- <br /> ------------------ -- ----..._...._....----- --......._. -------------------------------------- ............ ......... -------------------- ---------------- ---------- ..............--­ . - ---. <br /> ------------------- --- •- .. -- ------------------.. ----- <br /> r ------------.---- -- -----•---- - ------- jf - ........_ <br /> 1al Inspeciion by:.........i�� <br /> -- <br /> Date } --- - ---.--------- ...... <br /> F13 24 SAN LQUIN CAL HEALTH DISTRICT F&S 21677 REV. 7/763M <br />