Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT - <br /> ------------------------------------------------- (Complete in Triplicate) Permit No-------7-.SS / <br /> --------------------------------------------------- <br /> Date Issued-/./�-X-�--__;72 ' <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 /> # <br /> JOB ADDRESS/LOC TION-./� / S'G'�'�. L�/ i -- � f' CENSUS TRACT ,------------. <br /> �� Pho <br /> �� , <br /> Owner s Name._ ---- -- --- -- -� - <br /> i ------ <br /> Address - Y ! �.� _ <br /> 1 ------ Lic nse # f �l <br /> Contractor's Name.G � - Ph n - - <br /> Installation will serve: Residence} Apartment House-E] Com er ial ❑ Ter Court f <br /> e <br /> - - 1 <br /> Motel❑ � - -- --------- - <br /> Number.of. bedrooms Other-Garbage Grind / Size { <br /> Number of living units:---- -,- � �- --- of .- ----�- ----------�-- <br /> Water Supply: Public System and'name-- =-:--------------- ! -------------I------- '� --- --- ------------------- - ivat <br /> Character of soil to a depth of 3 feet: Sand ❑ -Silt[] lCl.ay'❑':T<Pe. ndy Loam Clay L am ❑ �4 <br /> I Hardpan ❑ Adobe ❑ Fill Material.........._af ° t pe- ---------------- -- ------- <br /> (plot plan, showing size of lot, location of,system in reloti n towel ; bu' dJ{ gs, etc. ust be placed on reverse iclF`, ` <br /> septic -; rp p „!iI if u ;ic sewer i ble w' in'200 t, <br /> NEW INSTALLATION: (No.(NoSEPTICTANKr seepage rt erm� r , <br /> 7P P;:r._AGE TREATMENT [ ] [ e_� , ZQ' -------- ----------- Li u id e� �' <br /> Capacity. :...........:.... yp l s o Co rt s <br /> T e-- ial - <br /> � f <br /> ' . . Distance to nearest;.Well----------- -_ ---- -'--------�Found ion..- Pop: Lin -}-..�C�r---------� � <br /> LEACHING LINE [ :] No. of Lines. - Le th f,;e+'c line _--.__ ----- -.__Tota Length,_ .- - f <br /> --- ------------------ i <br /> D' Box.--- ---Typ Filt Matbri I_- i De th Filt Ma erial-.--_--- ; --- r <br /> l g � i <br /> Distance to neares : Wel --�-. ___ --.___Found iron_ _----.Pro rty Li __.- _ r-: <br /> Depth - Di meter.: - .Number = = -` k Filled Yes ❑ No ❑'� <br /> SEEPAGE PIT [ ] p f. <br /> ;._ _ .. <br /> Water Table'Dept -. ---- a ck Sizer `' <br /> i ty, <br /> Distance to neares : W ll "- --_� '--- ndafion ----- -----------------Prop. Line--f------------------------- <br /> t ` <br /> ` i . ate-----------------------------------------------1 I <br /> REPAIR/ADDITION { rev. Sanitation Permit#- ._..- - -- --_- - . <br /> #: ,. <br /> t <br /> Septic Tank (Specify equirements)---- ------- --- ----- - = ----------------=-----=---=----------- ---- <br /> 1 , <br /> y i -�~�1 <br /> Disposal Field (Specif Requirements) ------- L`---------------- -' <br /> _. T <br /> ------------------------ <br /> ----------;---------- - ---- --- _ <br /> ---- ------- ----- 1} <br /> r -- - -�_ <br /> - ------------------------------------------------------------- <br /> ------------------------- ---------------------------- <br /> ----_____--. ____--- ___-.'-.______---_---s <br /> It- .(D------------------- <br /> -r sting and required addition:on reverse side) <br /> i a licationand-that the-work-will-be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this pp <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: 11 <br /> "I certify that in the perForriiance of the work for which this permit is issued, I shall not employ any person in uch manner as <br /> to become subject to Workman's Compensation laws of California.': .w <br /> -------Owner =� Y <br /> Signed. - �- =--=-------- ------- r--------= :.` <br /> B - - - - -- - -- - - ----- - <br /> = = <br /> Title Z ----- ---- - <br /> (If other than owner) <br /> r :FPR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE'.`---1`r---- ---~--- -------------- <br /> r 1� <br /> DIVISION OF LAND-NUMBER-.------------- - ----------------- ------------ -- ------DATE_---------------;- ------------- ------------ <br /> ADDITIONAL COMMENTS --=----------._�--------------------_:-------=------= ------------------------------------------------------ ----------- <br /> --- - <br /> -------------- ------- ----------------------- ---------------------�------------------ ----- ------------ ----------- <br /> '--------------------------I - I - ---- ------- ------------------ <br /> --------------------- -------- <br /> r <br /> - ----- <br /> -----------------------♦ .. -- ---- ------ -------------- <br /> ---- <br /> Final Inspection b ;. - = - <br /> _ �� .� ... <br /> Date <br /> Ek 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&s 21677 REV. 7/76 3M <br /> L <br />