Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION POR.SANITATION PERMIT <br /> ------ '-------------- -------- ------- <br /> � {Complete;in Triplicate} Permit <br /> f, Date Issued_. <br /> ------------------ ---------------------I 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 Ordi e No. 549 and existing Rules and Regulations: i <br /> T:FJOB ADDRESS/LOC ON_�Dt .`. -- - ------------- -------- -- - i CENSUS.TRACT - <br /> Owner's Name------ -- --- . Phone <br /> Address - - - -- - - City - -- -- --------- - <br /> Zip <br /> Contractor's Name--------- :License #Y Phone--------------------- <br /> ---------- -- <br /> Installation will serve: i Residence ❑ Apartment-House:❑" ;Commerc ❑;* Tr 'ler Court E] <br /> Motel ;❑ Other <br /> Number of living units:___--C. _._.__Number of.bedrooms ,_-/ --Garbage Grinder =-- Lof='Size_--.,_ ._-:--_-.__./".-".""" "- ". _-""._ ---- <br /> Water <br /> -Water.Supply: Public System and name------ =--- ---- ----------------- E Private [ <br /> s Character of soil to a depth of 3 feet: Sand Q Silt❑' Clay ❑. Peat❑, NSandy_Loam ❑ Clay Loam ❑ ' <br /> ' - p -!-•-Adobe.❑ "Fill Materiallfyes-type^-^-�-____ <br /> r -I -.a -� Hard an i- <br /> g <br /> (Plot plan, showing size of lost, location of system-in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW JNSTALLATION: ;(No;septic tank:or se age pit permitted if public sewer is available within 200 feet,] = <br /> ! / / F / Q <br /> PACKAGE TREATMENT "�']'1-SEPTI C. <br /> TANK .] „ * Size : x f , ___::"' .::__ _____Liquid Depth ."_-.""..".-"__ 7" <br /> -Capacity _ _- TypeMataria!__:_ No:'Compartments _'__------- <br /> : <br /> y Distance:to nearest: Well_______ V"___________________.:,_'Foundation._=____ _Y._=_____.Prop. Lin;` - _._____._ "_"Sb <br /> LEACHING LIN _ ] No, of Lines......_._______°._____.Length of each I-ine._____�. _Q_ _._____..Total',.Length __ ----------------------------------- <br /> E <br /> 'D' Box---- ---_--Type Filter Material_.__- -_.f-S�__Depth Filter Material__-__- - El-- ------------------------ ------- - --- <br /> Distance to nearest: Well <br /> -----------�----------Foundation-----------------------------l e-------_�----- ----------- --- <br /> : ---- -. Pr p y Lirl <br /> SEEPAGE PIT [ Depth.._ iameter_ _ ._�`___Number___i__.__--__ olertR�k Filled Yes ( No ❑ <br /> { rr l -- <br /> Water Table Depth Rock Size `( ------ t <br /> F yf Distanceao nearest: Well----._l__-`-Q.__""""":"_"""""_""_".Foundation_.__._.�.�..__...____.Prop. Line-. __"".__"_""_". <br /> r i F <br /> REPAIR/ADDITION (Prev�Sanitation Permit#---------------------- Date---:----------------. :'---` <br /> ------------------ <br /> Septic Tank"(Specify Requirements]---- ---------------=- ------- ---------------------------------------- <br /> { <br /> Disposal Field (Specify Requirements)=-------- -------------------------------: : ------------------------------------------ <br /> ------ . <br /> ------------------ -----I_-._"--__"--.____._"--___.____-_-._---.__._""__-• _ _ _ _ ." ----------------- <br /> "_ __ ------- ________ __-"__ -------_------------------_-- ._____"""_"-""_.""._"__". _._ <br /> �*• ,�. (Draw existing`and required gddit on on reverse side) `F"- <br /> I hereby certify that I have prepared this application and that the work`will be done in accordance with San Joaquin County <br /> I` Ordinances, State Laws; and. Rules and Regulations of the .San Joaquin Local Health District,,Horn_e owner or licensed agents <br /> signature certifies the following: <br /> "I cern that in the k <br /> certify 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 ------------------------------ = itle .... - <br /> If other than :owner[ <br /> f OR'DEPARTMENT US�ONLY <br /> APPLICATION ACCEPTED BYDATE.--- <br /> DIVISION OF LAND NUMBER:-----:_--,--:-_-------------------- - DATE-------------------------------------------- <br /> ADDITIONAL <br /> --------- - 'ADDITIONAL COMMENTS = ------------------------=------------------- ----=--- - -- ----------- ----------------------------------:--- <br /> -------------------------------------------------------------------=---- -------=------------------------------------------------------------------------------ --------- <br /> ------------------------------------------- ---- - ----=------ ------------------------------------------------------------- -� <br /> Final Ins ection b . _P Y!- = - ---------- ---------- --Date---- <br /> --------------------------- <br /> EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M <br /> F� <br />