Laserfiche WebLink
" FOR OFFICE USE �}� FOR OFFICEUSE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No/7._- <br /> (Complete in Triplicate) �7 <br /> �! <br /> Date Issued�:�----- - <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---ISS.. 0---------iAJ <br /> CENSUS TRACT t <br /> Owner's Name----- �C3-�_�----- /�,14�4�r_l_�.. --------------------------- -------------- ---------------------------------- Phone--------- ---------------------------- <br /> Address------- -��r' �.--------4�q'------GA �-------- -------------City -ma=y------------------------Zip--- _7------- -------- <br /> Contractor's Name ------- - -------- ----License #----------- ---------------Phone--------------------------- ------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--------------- - -------------------- ---- <br /> Number of living units:-----/-----____Number of bedroom s_---.Garbage GrinderJwO-----Lot Size----------------------------_----__------.--.__---__----- <br /> Water Supply: Public System and name------ ----------- -----------------,-- _. Private ❑ <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 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,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [ ] Size--=---_-_------------------------------------------------Liquid Depth.------------------------� <br /> Capacity --------------------Type-----------------------Material-----------------I--------No. Compartments-_,---- - ------------------------� <br /> Distance to nearest: Well-------------- ------ ---- k- —___=17oundation- ------------------------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- <br /> ----------------=----------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 /> SepticTank (Specify Requirements)------------------------------------------------------------------------------------------------------------------------------------ <br /> Disposal Field (Specify Requirements y-.-- .Ag.'-.-c4'..,--04,h----_ +IN4�__>__--1NS1FA-�C-_____T� f"'-__7+► 1 ---! e��°' - "---_• <br /> tevs-fIll-----J1V/VJff------------------------------------------------------------------------------------------- ---------------------------------------------------- <br /> -------------------------- ---- -------------------------- ------ -------------------- -------------------------------------------- <br /> (Draw.existin 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 WWor an's Compensation laws of California." <br /> Signed :_. ._.-./'f ----------- ---- --------------------- ----Owner - <br /> BY--------- -------- - -- ---- --------.Title-------- ----- --------------- --------------------- -------------- <br /> (if other than owner) <br /> FOR DEPA NT NLY <br /> APPLICATION ACCEPTED B ---- ---..._ - s DATE <br /> DIVISION OF LAND NUMBER - --- DATE <br /> ADDITIONAL COMMENTS .---__ f -Gtrze - <br /> . � ' ----------------------- ------------------- <br /> ---------------------- <br /> ---------------------------------------------------------------- <br /> - --------------------- <br /> 7 R <br /> Final Inspection b �'•--�-�------- -- -------------- - ----------- ---------- ------- ---- ---Qate-- ----'A-- ---! <br /> pY- ------------------------- -- ----------------------------------------------------------- ----------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV, 7/76 3M <br /> --- <br />