Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---•---•-•----------------------- ----- Permit No 7?- 3/Y <br /> (Complete in Triplicate) <br /> ------------------- . . . . .:---..... 7Date lssued..`V "- . <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.. � .. J(f�!.[- Com.... ... •-•----- CENSUS TRACT_A <br /> Owner's Name.... . - - ...... T .... ------------------------ Phone <br /> ­-----------__------- <br /> Address------------- ....... _ . .. City. ! Zip <br /> Contractor's Name.............. . ...... .Q.�...� L9'dlrt- - -- . . .....License #._�[�- f._ .PhoneLj ` :v� � -- ------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------- --------------------- ----------- j <br /> Number of living units:---....-!_----Number of bedrooms...__ Garbage Grinder------------Lot Size...---�X 4 �--- <br /> Water Supply: Public System and name---------------- -- - __---------.--------------..Private <br /> p p ❑ ❑ ❑ Y❑ YP y -❑.. - ..y oam ❑ <br /> Hardpan Adobe Fill Materi If es, type -- <br /> Character of soil to a depth of 3 feet; Sand Silt Cla Peat Sand Loam a L <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..----_-----_------..:No. Compartments ----••----------- --------------- <br /> Distance to nearest: Well----------------- ................Foundation.......... --....... _..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.---------------------..-,.Property Line-.--------------------------------. <br /> SEEPAGE PIT [ ] Depth--------........Diameter_..........-.. Number. ------ Rock Filled Yes ❑ No []� <br /> Water Table Depth-----------------_- ---------- ....---Rock Size-------- .......... ............... -- <br /> Distance to nearest: Well.............. .... -------- ------..Foundation_... --------- ... --..Prop. Line.-----= ------------- <br /> REPAIR/ADDITION <br /> -----------REPAIR/ADDITION (Prev. Sanitation Permit#------------------- -------- ---- - ........Date_ --------- ------- -- <br /> Septic Tank (Specify Requirements). ----. . <br /> Disposal Field (Specify Requirements).-.-� � ...........r `' � / ... <br /> ------------ -- --- <br /> __zz - -----------------------------..........------- ----......--------- <br /> --------------------------------------------------------- ----------- ---------------------------_.-.---...-..------------.-..------------..............---- --.-.-.__.... <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 County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hayne 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 subje Workm Is Co pensatio+� laws of California." <br /> Signed------- s. Owner <br /> By................ -------_-. ------- r LL/ ...... Title a ...------ ---- ---- ------------- ------------- <br /> (if other than owner) <br /> FOR DEPA T ENT USE ONLY <br /> APPLICATION ACCEPTED BY /l-- ----- --- y'^'" -------------- <br /> DATT 2DIVISION OF LAND NUMBI=R._... --------- DAT .__... - -... <br /> ADDITIONAL COMMENTS-------------------- -----• ------ -- ...... ........ <br /> -------- <br /> -----------------------­­ ------------ ---- . -- ---..... -------•-----•-- ----- ............- - -- •---- ------ <br /> ......................... ................. L .---._....----------- ,--......._....----....-......---------------.-------------.---------------------------------------------- <br /> .- <br /> Final Inspection b n-. -- - ----- - ------ ----- - ----------Date I� .. . . 1677._ . 6 3 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />