Laserfiche WebLink
FOR OFFICE USE: V FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- --- - �------------------------ -------- it No. -- <br /> (Complete in Triplicate) Perm7f—al <br /> --------------------------------------------------------- <br /> Date Issued.-.r _-z� <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____Z--�- - - --.--'-i_------- A- <br /> ----------------------CENSUS TRACT--------------------------------- <br /> Owner's <br /> --------------------------- -- <br /> Owner's Name.-/-- ----- -------- ------------------- ------- -- Phone-- ---------------------------- ------ <br /> Address---------.-/-5ZI--------- -- ---- --- ----------------------- ----------~--------City- --- --- -----Zip--------------------- -------- <br /> Contractor's Name----------- �_--- ---- °-------------------------------- License #------- - _.Phone------------------- <br /> Installation will serve: Residence-[r, Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------- -------------------------- <br /> Number of living units:----/---------N.urnber_of_bedrooms__.-c3----Garbage Grinder------.-----Lot.Size- _.:____. g <br /> ------------- <br /> Water Supply: Public System and name--------------- ------------------------------------------- - Private ['7 <br /> Character of soil to a depth of 3 feet: Sand E-1Silt E],­ Clay E] Peat E] Sandy Loam ❑ Clay Loam ❑ <br /> 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public-sewer is available within 200 feet,) r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK '/ - ` �-/ _�� _ S/ <br /> [moi Size== ------------------Liquid Depth--------------------------- " <br /> Capacity_1*_'--------Type- --------------- -- Material No. Compartments...;�7'........... ------- <br /> Distance to nearest: Well--------_,5;�p----------------------------Foundation------/47-- ---------Prop. Line----�-------------- <br /> ----fi <br /> LEACHING LINE [� No. of Lines-------..3 g <br /> Length of each line �a <br /> 6 Total Length ------------------ <br /> D' Box-----/---..--Type Filter Material__-S----------------Depth Filter Material---157---i;--- .-------_________--------- ----- <br /> Distanc&to nearest: Well------ D---------------Foundation.___ l------------------ <br /> Property Line_. '1 --------` <br /> SEEPAGE PIT [ Depth..�r_ Diameter...-.--;�!.3_/'.Number----------------3------------ Rock Filled Yes rr No ❑ <br /> Water Table Depth-----------------�-CJS -------------------------- Rock Size---,/ -------------------- , <br /> Distance to nearest: Well-------_/_Q-0--------------------- <br /> ___Foundation------- -------Prop. Line______--_-.----_._-__ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date-.---------------------------------------------} <br /> Septic Tank (Specify Requirements)------------- s= <br /> DisposalField (Specify Requirements)------- -------------- ---------- ------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- ----------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 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 - Owner <br /> By-------------------- --------- ------------------- Title- --------------------------------------------------- <br /> (if <br /> G`c'cJ __ ____ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED, - <br /> -- - 1---____-__------ <br /> DIVISIONOF LAND NUMBER---------------- -------------------------------------------- ---- ---------------------DATE----------------- - ------------ --------------- <br /> ADDITIONALCOMMENTS-------------------- --- ------------------------------------------------------------ ------ <br /> ----------------------------------- -----•--------------------------------------- ------ --------------------- <br /> ---- ---------------------------------------- ------ - <br /> Final Inspection b --.-.-.-Date.--_- =___ <br /> p Y - - --- ---- <br /> EH 13 24 �S44 JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> �7 <br />