Laserfiche WebLink
t <br /> r FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------- <br /> ------------ ---- ----- - - Triplicate) Permit Na.-.:7-f" 37 2- <br /> -------------------------------------------------- <br /> ! <br /> (Complete in <br /> -------------- ------------------------------- Date Issued-.-5_,12_3=-7_ k <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/LOCATIO Som-_ "---A_--------------------------------------- ----------------- CENSUS TRACT -.---- <br /> .Jj-_j <br /> Owner's Name ---- ------ ---'-� � - -- -- ---- ------------------------------- ---- ------- ------- -- --------------- <br /> -----------Phone- `. t <br /> Address-Zy.Zy_ =x !,``----- -------------------------------City. - zip--- <br /> se <br /> Contractor's Name- n -------------- ------------ #_ ---a�'`t�------Phone--�_r� "r � <br /> /// Q <br /> Installation--will-serve: - - Residence Apartment House [:] Commercial E] Trailer Court ❑ ��'. <br /> Motel ❑ Other---------------- ----- ---------- ---------- <br /> Number of living units:----------------Number of bedrooms_ -------Garbage Grinder------------Lot Size----------------------------------.--- -__-------- ----- ` . <br />€ Water Supply: Public iSystem and name--- ------------------ --------------- ---------------------------------------------------Private <br /> L Character of soil to a depth of 3 feet: SandE]. Silt 0 :Clay ❑ 4Peat-❑ Sandy Loam �ay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material-__.__ 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 perrxiitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK <br /> ] Size------------------------------------------------------------Liquid Depth ------------------- ------ <br /> -e-* Material Na. Compartments <br /> Capacity _._ .-- yp12-1 f <br /> Distance to nearest: Well_ a...___._ - Foundation_ ------------------Prop. Line-_ _�_- �,. <br /> -------- ---- p� f <br /> LEACHING LINE [ ] No. of Lines________---____------._.Length of each line.----T� . --- __-Totalength... -- _.---_.___----_____----___ <br /> - - --------- <br /> j 7 <br /> 'D' Box_1-_---__--Type Filter Material _- t Depth Filter Material_,;___4 <br /> Foundation-------------- pert Line----------- -- -- <br /> 4 Distance to nearest: Well---------- --- ----- Property <br /> SEEPAGE PIT [ ] Depth-----��-_Diameter____ �:.__,.�Number_��-`�------------------ �wRock Filled Yes [-] No E]Water Table` ' -� ` .Rock Size----------------------�------- ---------------- <br /> Depth. <br /> Distance to':nearest: Well----------- ------------ -- s.----------Foundation-------------------------.Prop. Line--------------------------- <br /> REPAIR/ADDITION (Prev,'Sanitation Permit#----------- -_- ------- ----=---------------Date--------------------------------------------- ) <br /> Septic Tank (Specify Requirements)----------------- ---------------------------- ------------------- <br /> Disposal Field (Specify Requirements) --------- &' ----------------------------------------------------------------------------- <br /> ----------------------------------------------------- - -------------------------- ------ --------------------------------------------------- ------------ <br /> ---------------------- --- --------------------------------------------------- <br /> -------------------------------- --- ------- - ----- -- --- - - <br /> E (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 /> 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 /> 5igned__�,�"�---- ---------------- ----------- ----- --------- ---- - Owner <br /> ------- --------------------- -- <br /> Title-- ------------------------ -------------- ----------------- ----------- <br /> BY---------------:------------ <br /> (If other than owner) <br /> FOR DEPART ENT USE ONLY /y <br /> APPLICATION ACCEPTED BY -----------------------------------DATE -------------- <br /> DIVISION OF LAND NUMBER----------- -=-- ------.DATE <br /> ADDITIONAL COMMENTS------- --------- ------ --------- ------------ ------------ ------- <br /> ---------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------- <br /> -- - --- -- --- <br /> ------------------------------------------ -- - <br /> ----------------------------------- ---- ----------- <br /> -- <br /> Final Inspection by. . ------ -Date------ ----- 3-` ------------- <br /> ; <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 21677 REV. 7/76 3M <br />