Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT z <br /> (Complete in Triplicate) Permit No/O.- - <br /> --------------------------------- ---- -------- ----- <br /> Date Issued-5.Z,l�..1?& <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 /> � r ,. . <br /> JOB ADDRESS/IOCATION... yy CENSUS TRACT................... . .... . <br /> u...✓....... .. ... . <br /> Owner's Name...... .... 1 ......Phone....----• <br /> , af� fid '-=t ... ---------- ..... ---------- -- <br /> Addre•5�V�...-17lJ ---- - .., V i .....:... . ---city............. ----------------------.--------Zip --------- ------ ----- --- <br /> Contractor's Name___ , <br /> �jj <br /> y " (i License #. .�-,7 7/--..Phone...�?...1�.��L�-. ..- ... <br /> Installation will serve: Residence,M Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> pp Motel ❑ ',Other.-..------------------------------------- <br /> Number <br /> ---------------------------------- y <br /> Number of livingunits:- I,-.f.-....---Number of bedrooms.__! <br /> � .__.Garbajge.Grinder------------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 f <br /> Hardpan ❑ Adobe ❑ Fill Material.. ... ....if yes, type-.--..-------- <br /> IPIot 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 ...l,t Liquid Depth..-91................. ..� <br /> Ca acit �. _o T e-.. Material._. l.._..No. Com artments.... <br /> A y. YP —,?r-... .. P t ; <br /> �. . M .. <br /> Distance to nearest: Well..__./_.. Foundation_.___/._t7. ............ Prop. Line---.. ._......... <br /> LINE [ ] No. of Linesl � € Total Length .L P...:........................� <br /> = Length of each Hne. > e g <br /> LEACHING_ ......Box.... <br /> � ho Distance to nearest: Well.-�, :. _.Foundafiion__„_�:�.._.__.._... Property Line.....b.......................... <br /> -5f-SPAISE-PtT [ ] Depth...311D..M."ADiamerer....................Number-_...___V,------------------- Rock Filled Yes [A No <br /> Water Table Depth------•-------- ------------4, �-- -------------Rock Size-- -- ... ... -------------------------- <br /> Distance to nearest: Well.:.. . ....._ ,._...--.----Foundation....._- ..... ......Prop. Line...................__..... <br /> REPAIR/ADDITION {Prev. Sanitation Permit#......_........................ .. ...............Date.............._ ............................ <br /> Septic Tank (Specify Requirements).... . ................................... <br /> Dis osal Field (Specify Requirements)................ -------------------- - .............. <br /> --------------- ----------- ------------------- <br /> {Drow existing 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 Son 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, l 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- C- --- -------- <br /> ------ Title....-- ----------------------- -------------... <br /> 11f other than ow r[ <br /> FOR VPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- - -- - .-- ----- - ---- ........ - ---- -------- ------------.........DATE -.--90-�` <br /> 70--- ...... <br /> DIVISION OF LAND NUMBER.-- -.- - -- � ..-- ............. ------ ...DATE.-- -......---- --.......... ---------- <br /> ADDITIONAL COMMENTS... -------- ------- -----------------------------.... ----.... ... ....... <br /> ----------- -------- - ------­­.. ---- ------------ --------- -------- ----------- --- ------------ -- - ----...--------------­­­------------------ <br /> ----------------- -------------------------------- - -- -------- --- ------ --- ... . --- <br /> Final Inspection by.- Date.-.._�.. .l$ �� --- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 2;e77 Rer.0sM <br />