Laserfiche WebLink
OI <br /> FOR OFFICE OSE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------- ------- --------------------------- Permit No.----� <br /> - �6 <br /> ' (Complete in Triplicate) � <br /> ------------------------------------------------- <br /> Date Issued..____S_-1___S[____.F_ <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 Ordinance No. 549 and existing Rules and Regulations: . <br /> JOB ADDRESS/LOCATION . . a .. -1#3• - - - --------------------------------------.-•---.CENSUS TRACT <br /> --------------------------------- <br /> Owner's <br /> ------ -- --Owner's Namep. pb ------- <br /> . .. . <br /> _ -- zoos <br /> ------------ ------ --------------------------------- -``LLI -- <br /> Address_ ---- --- - -- -- ---------- <br /> City---- ---------- ------- --'--" ZiP----------=------------------- <br /> Contractor's Name--------------------- --------- - ---------------License # :3Y. ------Phone_ / <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ ' <br /> Motel ❑ Other---'-----------==---------------- <br /> ,. <br /> I <br /> Number oflivingunits:______(._.______Number of bedrooms--_,�_.-__Garbage Grindex___:________Lot Size ----- k l�rt� , - <br /> Water Supply: Public System and name----------------------- - ----------------------------------- --- -- -_ .j - -------- ------"-----------:_-----------Private❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> I ` Hardpan ❑ Adobe Fill Material-------------If yes, type______________________________ <br /> ]Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] i <br /> NEW INSTALLATION: '(No septic tank or seepage pit permifted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ['1 Size-----------------------------------------------------------Liquid Depth-------------------------------------------------- <br /> Capacity- -- -------Jype------------------------Material--------------- - --------No. Compartments-------------------------------------- <br /> Distance <br /> ------ -------------------- -----Distance to nearest: Well - ' -- ----- ------ ----- - Foundation-------------------------Prop..Line--------------------------- ;0 I <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 /> Water Table Depth--------------------------------------------- Rock Size-.-------------=-------------------------------- e <br /> Distance tc nearest: Well------------------------------------'-------Foundation--------------------------Prop. Line-:---------------------'-- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------_--------_-------_------------Date------------------------------------- ___) <br /> Septic Tank (Specify Requirements) = - ------------------------ ---- <br /> ------=-----=------- ------ --- ----------------------------------------=-- <br /> Disposal Field (Specify Requirements)----------- .-------� -----YJ1Cr(—CA......... �--------- ------ ----- -------------- �: <br /> --- ------------------------------------------------=----- = " n ------------------------ ------------ -- ---------------------------------------------------- <br /> ---- --------------------------------- ----------------=- - - . - <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 /> signature7 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-------------- - ---------- ----- -------_--- -- -----Owner <br /> B -- -- -- -- ` = = Title- ----------- ----- ------------------------------------------ ------ <br /> Y -- ' <br /> other than o ner) <br /> R DEPARTMENT USE ONLY <br /> -DATE..- S` <br /> APPLICATION ACCEPTED BY 7 <br /> DIVISION OF LAND NUMBER:-- ----- --"- -- - --- - ------------------------ --- ------ DATE---------- <br /> -------------------------------- -- ----------_--'- --- - -- <br /> ADDITIONALCOMMENTS---- ------ --- ----- - -------- ---------------------------=---------------------------------- ---"----------------------------------- :-- --------------- ------ <br /> - - ------ --------------=-------------------- ------ ------------- <br /> ----- -------------------------------- � <br /> -----=--------------------=--------------------- -- ----------------------------------------------------------------------------------- <br /> - - <br /> j <br /> -- - ------- ------------ --- <br /> 11 <br /> . ----------------------- <br /> ---Dote-__Final Ins ection=b - ------ -----------------------'-------------- -- /- --_ -- ---- ------------------------- <br /> EH 13 24 JOAQUINLOC EALH DISTRICF&S 21677 REV. 7/76`3M <br /> qrt c-' I <br />