77-42 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - --- ---------------------------------------------- 7 7_ yz_ (Complete in Triplicate) Permit No_________________ _____ - --------------------------------------------------- - LY Date Issued.__i-/J-.7-i This Permit Expires 1 Year From Date Issued --- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION- -j ------- -- ------------------ -----------------' CENSUS TRACT--------.------------------------ - Owner's Name- ----- - Phone-------------------------------- Address-------------- r --- --------- ---------------------------------City-- YL--------.zip---------- ---- --------------- Contractor's Name.......... `__.- ----------------_---------------License Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------ -------------------------------------- Of Number of living units:___/_—Number.-of bedrooms___Garbage-Grander.-_ Lot,.Size—Z75- ______________________` Water Supply: Public System and name---------------------------------------------------------------------------------- - ----------------------------------------.Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material-------------If yes, type________________________________ (Plot plan, showing size of lot, location'of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE: TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth.----. ------------ -- CapacCapacity-------------- ity-------------- ----- Type---------------------- _-No:-Compartments-------- --------------------- -- Distance to nearest: Well--------.--.-_--------------- ------Foundation.-------------------------Prop. Line--------.------------------ LEACHING LINE [ ] No. of Lines__________ ----------- -------Length of each line________,_________:_________.Total Length ._-__-.__-_ 'D' Box------------Type Filter Material--------------------Depth Filter Material___________________ Distance to nearest: Well----------- Foundation----------------------------Property Line----------------------------------- SEEPAGE PIT [ ] Depth----------------Diameter----.-------- Number-------------------------------- 3"- Rock Filled Yes ❑ No❑ Water Table Depth ---------------------------------------------------------Rock Size-------?......'-------------------------- Distdrice to nearest: Well_---------- ----------------------------Foundation--------------------------Prop. Line--------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#___ ______________________________________________Date__..___..___..___._______________.._-__.__----) Septic Tank (Specify Requirements)--------- ----- --------------- ---- of --of Disposal Field (S ecify Requirement) r �r �-� - ------------------------ ------------------------------------------------ --- --------------------------------------------------------------------- ------------------------------------------- ------------------ ------------- -------------------------------------------------- - ---- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "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 i to become subje t W rkman's . mpen ation laws of California." Signed--- ----------- -- ------- ---- y Owner - $Y ------------------------------ �'+-`----- - ------- Title [If other than owner) FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ?�� --- ----------------=--'------ ---- -----DATE DIVISIONOF LAND NUMBER. --1- - --------------------------------------------------------DATE------------------------------------------------ r ADDITIONAL COMMENTS--------`�--------------- ------ ------------------ ------------------------------- ------------------------------------------ ---------------------------------------- ---- ------------------- - -------------- --- ----------------------------------- ------ - _2- 1l 7, -------------- ..--_..-- .n--- -- ---------- __ ..___.__.-------- --- ---------------------------- -------------------- U T = T� � ----------- ----------- -- ------- -- - -------------------- -------- - Final Inspection bY:-- ----... ---- 1 Date. EH 13 24 SAN JOAQUIN L09<L HEALTH DISTRICT F&S 21677 REV. 7/76 3M