Laserfiche WebLink
jFOR OFFICE USE., APPLICATION FOR SANITATION PERMIT <br /> i <br /> ..........i....................................... 7,5 ssviVt <br /> -• � Permit No <br /> i {Complete In Triplicate) " """"` "" r" <br /> :.......,...::....................................... 7 S` <br /> TDate issued . �. .�.. <br /> .........:............................... This Permit Expires i Year From bate Issued <br /> Application is hereby made to the San Joaquin local Health District for a permit to construct and install the work herein <br /> described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulations$ <br /> , <br /> JOB ADDRESS/LOCATION ...... ..................:......CENSUS TRACT ............ ..... <br /> Owner's Name .....:.....�1/'X J �`. :Y.?.. ...... � _..� . _ ........... ........... .........Phone . I`:... -4.......................... <br /> Address ............ ...... . .................................... <br /> . ... •-------- ----....-----...............'City ..3� A. raY....................... -- <br /> Controctor's Nome <br /> ,.r��rK '�Z.geq....�...a CVV .----•..................License Phone <br /> instlaliation will serve: Residence g Apartment House(] Commercial OTrailer Court 0 <br /> it <br /> ilk Motel Q Other ........................................ . <br /> Number of living units,.... .,..- Number of bedrooms ...3.1.. Garbage Grinder ............ Lot Size .aOf��YPs <br /> Water Supply: Public System and name ...................•...................:............. .............................. <br /> ....•--•................Private <br /> Character of soil to a depth of 3 feet: Sand r] Silt❑ Clay ❑ Peat(] Sandy loam 0 Cloy Loam'a <br /> Hardpan ❑ Adobe [3 Fill Material ............ If yes,type p� <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 ( 7 SEPTIC TANK( j Size.1'r.!1�� .i�`. ..................... Liquid Depth ...�1r..:�............. <br /> Capacity /000 &g Type/61C.X457' Material..Cam C..... No. Compartments .;Z................. <br /> Distance to nearest: Well ........ ...............Foundation Prop. Line/ ............ <br /> LEACHING LINE ( ] No. of Lines ....... ............ Length of,each line......� ............ Total length 36 <br /> 'D' Box .3...... Type Filter Materials '&tt.....:Depth Filter Material ..........-7.0 .................... <br /> ,� O . Foundation 3o s Property O <br /> i Distance to nearest: Well .... ..0...........: ........................ Pro Line .�................... <br /> SEEPAGE PIT [ ) Depth .................... Diameter ................ Number .......:..............,..... Rock Filled Yes d . No Cl— <br /> Water <br /> ^"- <br /> Water Table Depth { <br /> ' .:.........Rack Size <br /> Distance to nearest: Well ..........................................Foundation .................... Prop. Line .......... 4 <br /> REPAIR/ADDITION(Prov. Sanitation Permit ............................................. Dale ................................ .) ; <br /> Uptic Tank (Specify Requirements) .........% ................................................................................................_............._.................. <br /> 1�isposal Field (Specify Requirements) <br /> .... .i ...................................................................•--.................... .............................................. .............................................. . <br /> . ......I..........1-1........................................................................................._...............................................................I......I.......1"............ <br /> (Draw 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 <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licm <br /> sedm9ents signature certifies the followings <br /> "1 Certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as io become subject to Workman's Compensation laws ollCallfornio." <br /> •E°. j T eS v� <br /> , <br /> Signed ..-...... !�................ 1............ .. .111.............................-.. Ciwner <br /> yIXitle ......................................:................................. I <br /> (If other t. — e''.. <br /> i FO DEPARTMENT SE ONLY <br /> APPLICATION ACCEPTED 8Y .... .� r .. . ...._... .. DATE—'— <br /> PERMIT ISSUED <br /> ...................... <br /> ........ .... ......... -.......................................................................-•- -•---,..-•---.........-----DATE ........................................... <br /> ADDITIONAL COMMENTS ......................................:.............................:................ <br /> l ............................................................ ....... ................----...............................----••. -----............ <br /> ........................................................... ................. .....................::.................._............................................... .............. <br /> ....: ........... ..... <br /> Findl Inspection by; ..... .. ......... .......... ......,..... ......I................................Date . fir.. : .: �� -............ <br /> SAN JOAQUI LOCAL HEALTH DISTRICT <br />`;F E. H.1-3 241•'68 Rev. 5M 7/72 3•M <br />