Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------- 77— <br /> (Complete in Triplicate) Permit No---_-- ----------- <br /> .___- <br /> Date Issued__--` <br /> --- Th is'Permit'trxpires 1�Year from Date Issued�`"� "` �-� <br /> F; <br /> Application is hereby made to the San Joaquin•Loca4-44eblth 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/LO t ION._F_�_ -� --- ------. 7p�_.. n rn <br /> -101 -------- IRNTfr 7 ': .CENSUS-TRACT-- - <br /> - - -- <br /> Owner's Name.---- -- �,- '-- ------: i- 1--�_i „". .' <br /> t , s <br /> . .f. -- -. -- ----------- h - . ------. -- --- -------- <br /> -'- - ---. . -'- � --�.- Pone <br />► Address----------- --- - ---`•- - - f <br /> City- rnk <br /> .-. I <br /> oneZIP <br /> .Mp_ ----- <br /> Contraetor's Nam ' Licene # --� <br /> 44,r <br /> Instal <br /> Installation well serve: E 1 ! Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Mote1l ❑ ' Other__ i <br /> { _ p ---.------------- ---- -- <br /> Number of living units:..'- '."...--.Number of bedrooms--- 1,. .a <br /> bedroom Gr.inded____�,.z,,„,t Size <br /> Water Supply: Public System:andname_.-..-- _ - I l <br /> F = -- -- --------------- <br /> Ha <br /> --- -- -Private <br /> Character of soil to a depth.of 3 feet: Sand ❑ Silt❑ 'Clay ❑ Peat❑ Sandy Loa{r�iA Clay Loam F-] <br /> i Hardpan ❑ Adobe❑ Fill Material-- -. If;yes, type _ ` + ---.-__ <br /> /}T <br /> (Plot plan, showing`size of Iot,Ilocation of system-iii-rel on+toE, �welYslbui�dings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION:' '(No :'s pfic #ank `or�serpage pit permitted if public sewer is available \rii irI 200 feet,) <br /> PACKAGE TREATMENT ., _ . <br /> [ ]` SEPTIC TANK ' -„ ` . <br /> � ].t-s}a-"i'- I ---- ize--� ---�-------------------------------------- -------- "squid Depth ----' ----- - <br /> P Y YP t Material-: :-- -_:--------No. Compartments --------" ------ ------ <br /> r . ., DistanceNo nearesf.Wehjl _. --- _= ,- - --- ------Foundation__�.�,,.----'------ ---Prop. Line------------------------- - <br /> LEACHING LINE [. ] No.;of Lines.._ _._ . •Length-of each-lirieY--------------- <br /> ---- Total Length. __..-- <br /> t\ �. <br /> D Box -. TypetFllter MdFterial �.ti Depth Filter�Material ----._ <br /> i i Distcince to nearest:sWell _-...-_—__-.--Foundation--- _-- -----------Property Line--------------- <br /> SEEPAGE <br /> .- -SEEPAGE PIT E ] Depth, __Diameter ..... -.Number /- -_ Rock Filled Yes ❑ No ❑ <br /> Water(.Table{Depth+_`- ----- - <br /> -.Rock Size------------------------------------------------ <br /> i s t: Y ry <br /> c Distance to nearest:,Well-- "_._ __.�.-.Foundation_____________________...Prop, Line-------- .---------------- <br /> e- <br /> -..___...-.- <br /> - <br /> REPAIR/ADDITION {Prey. Sanitation Permit#-t-------- .--_.. `" _.' Date= Y___;- _.-. <br /> s <br /> Septic Tank {Spec ify,Requirements)�__ €� -` > ; <br /> r ------------------------ ----------------------------- -- --- <br /> Disposal Field(Specify Re uirements)__ _ } , <br /> - ---- -------------- <br /> --- ' <br /> �.Fa <br /> , a --- ----------- ---- ------ ----------- <br /> --------------------------- <br /> ----------------------=-- -------------- -. <br /> - -------- <br /> i (Rraw ezi,sting and.r'equired addition-on reverse side) ; <br /> hereby certify that I have prepared this application and that4the 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 /> "! certify that inttellpeiformance of ahe work for which this permit is issued, ! shalf not employ any person in such manner as <br /> to becosub'ec Workman's Co pensati laws of California." <br /> Signed ; ' <br /> ✓� <br /> { (If other than owner) <br /> FOR DEPARTMENT USE"ONLY <br /> APPLICATION ACCEPTED BY..' =- "---- ------ - - -----------'----- ----- A-------=-------------- --D TE <br /> DIVISION OF LAND NUMBER-------------- <br /> - --- --------- ---------------------- DATE_------------- <br /> - ' <br /> ADDITIONAL COMMENTS--------- ----------------------------- <br /> ------------------- <br /> ------ -----:-- <br /> a <br /> ------=--------------------------------- -- -- ----------- ------------- - - --------------------------------------------------------------------------_----/----------...- ----------' <br /> Final Inspection b - - 7--:Date------ -' <br /> P Y = ' <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.'7/701 ,;f <br />