Laserfiche WebLink
FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No—�4 r7 <br /> -------------------- ------------------------------------ (Complete in Triplicate) <br /> -� <br /> --------------------- <br /> --------------------- Date Issued 3��-7 <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. 544 and existing Rules and Regulations: <br /> Q� ' ------CENSUS TRACT- ----------------------- - -- <br /> JOB ADDRESS/LO <br /> Owner's Name ---- <br /> l ---Phone----- -------------------------------- <br /> 3 .. ---------------- <br /> Addressy` CifiY Zip �o <br /> ---- <br /> Contractor's Name----- `. ----- -------------- <br /> --License #---rr-7 ✓'9 Phone_- ----------- <br /> installation will serve: Residence Apartment House El Commercial ❑ Trailer Court Ll <br /> Motel ❑ Other-------------------- ------------ --------- i <br /> Number of living units------- ------Number of bedrooms---1/ --Garbage Grinder------------Lot.Size_ .. <br /> Water Supply: Public System and name--------------------------------------------------------------- ------ ---- ------ <br /> --------------------Privatelx <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ 'Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material--.---- _-If yes,type-_----------------------------- _ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) Y <br /> NEW INSTALLATION: (No septic tank or se�eeppoge pit'permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] -SEPTIC TANK Size--_X--rr-'-x -- ---------------------------Liquid Depth.--r�----------------- <br /> Capacity.) <br /> -----.----_----_� <br /> Ca acity.- /-------TYp -}�,,- <br /> D - e�_ �a4�'--_-:Mate,ria!-�—a---------No. Compartments-------------------------- <br /> Distance <br /> -------� ----- ------ --� <br /> Distance to nearest: Well..,/6z:�------------------------------Foundation---/0--------------Prop. Line___5-_lam----- <br /> LEACHING LINE C"1 No. of Lines---.--_�-------------- Length of each line..-��5------gs- ---.Total Length.------�-w---------------- -- <br /> r <br /> 'D' Box_-- --Type Filter Material- 196CA- Depth Filter Material----- f--------------------( <br /> r ' <br /> -------------- <br /> ''--// Distance to nearest: WeIL_�C�Q-- .---.-------foundation.--- --1,----------------.Property Line--------------------- <br /> `Su� s [�f --tt� Xie <br /> Depth---f `--. 13iameter-- - Number---------P --.- ,, ,r Rock Filled Yes ' No ❑ <br /> Water Table Depth ----- q_0----- -�---------- ---------------- <br /> Rock Size--- - ��-------------- -------------- - <br /> Distance to nearest: Well-..-1��-----.- ------_.-Foundation...A AM- <br /> --------- Line_-f.�--/���`t---- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------- -----------------------Date--:-------------------------------------------) <br /> =--------------------------------- <br /> Septic Tank (Specify Requirements)---------------- --------------- ---------------------------------------------------- <br /> Disposal Field (Specify Requirements) --------------- --- --- --------- ----------------- ------ ------- ----------------------------------.------------------------------------- <br /> ----------------------------------------------------------------- <br /> ------------------ <br /> ------------------------------------------------------------------------------------- <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, Home owner or licensed agents <br /> signature certifies tate following: <br /> "1 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 becomeject to /�l/j. kman's Compensation laws of California." <br /> Signed_ l -e- 1 '---- --------------- --- -----------------Owner <br /> -- - �--- ------ ------- <br /> . ------------------------ ------ ---- <br /> --------------- -------Title---- -- --/----- --- ------- <br /> (if other than/Owner) r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- --�"�--- - DATE. 3""+ \�7 <br /> ---------------------------------- <br /> DIVISION OF LAND NUMBS ------------ DATE.. <br /> ADDITIONAL COMMENTS------------------ ----------------------------- --------------------------- <br /> -------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------- --- -------------------- <br /> - ------ - ------------------ --------------------------------------------------- <br /> ------------------------------------------ ----- <br /> �� <br /> I <br /> Final Inspection b CLf nom"` Date 7 <br /> ------ -------------------------- --- - <br /> EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />