Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT J <br /> ------------------------- --------- - Permit(Complete-in in Triplicate) <br /> -------------------------------------------------------- <br /> : .4 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. 549 and existing Rules and Regulations: rt _ <br /> JOB ADDRESS/..LOCATIQN...;�J'��._--- -- -------------- ----------------- --- ------- --= ---- ----CENSUS TRACT ...... <br /> 1 Phone <br /> - -- <br /> hame _ -- ---------,_....¢:-- ==r - - ------ <br /> city <br /> �, - ----P ---------------------------- <br /> Owner's ----�---- <br /> ._. <br /> Address f `e_ -- --------- --------- <br /> ---„- tY <br /> C� <br /> • r v <br /> Contractor's Name -' License .#_._ _Phone t <br /> _.F. .; .�.... -i.... ._.... <br /> Installation will serve: Residence [Apartment House E] ,FCommercial ❑ Trailer Court ❑ <br /> . Motel ❑ Other- <br /> C? ----------------------­---- -Number of living units: r___.-_Number of..bedrooms----c.3 Garbage.Grinder....------- _LotA Size ____._Q' `-'"'."" .-"_" ---.. <br /> F Water Supply: Public System and name_ = ` _ ,------ -•.----- :. :. - ! .:_.: -: _-.-... Private ❑ <br /> Character of soil to a depth of 3 feet: Sand [] :Silt❑ Clay❑ `Peat ❑ Sandy Loam Clay Loam ❑ -�-� <br /> Hardpan-]—Adobe ❑ ? Fill Material.._.-:----`.l#yes, type---------- --------------------- <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: (Nonseptic tank-;or seepage spit permittedl if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.. I, e. ------ _: ._----- --- ---------------Liquid Depth.--- -- ------------------- <br /> capacityType ---"---Material---------_-- '-No. Compartments--'-------------•-------------- C <br /> Distance,.to nearest: We11_,-.•...- ------ Foundation._. Prop. amine <br /> LEACHING LINE [.,] No., of Lines------------ :-_-"-.,_.,Length of each l.ins___:-.______.-'________"____-Total Lerigth __.__�_:_...._ <br /> ' 'D' Box-----------Type Filter Material------- ----------- Depth Filter Material--'--------------------------- --------------------------- <br /> Distance <br /> -- --------Distance to nearest: Well----------------------------Foundation___--_ -____ __-----------Property Line"--. ' <br /> SEEPAGE PIT I ] Depth---------- ----Diameter.-__----,------_----Number--- ---------.--- -__.-------_-- Rock Filled Yes ❑ No ❑ <br /> Water Table-Depth. -`k>--- ----------------------------------------Rock Size---------------------;------------;�----------- E <br /> F <br /> Distance to nearest:"WL-ll-_ ------------- ------------------- Foundation---------------------------Prop. Line------- --------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----:-----------------------------------'------ --_=--:Date-------.___:----------------------------------- <br /> Septic <br /> ---._--- _____-_.__._._Septic Tank (Specify Requirements( -------------I.--------------- --- - ------ --------------- = <br /> Disposal Field.(Specify Requir ments)_----t' --��r �*z`--�1�J �.� fi"r"F- -- <br /> --- ----- ------ -------------� %-------- -- ------- ------- <br /> ------------ . <br /> .� �� - ----- - ,✓ <br /> r (Draw existing and required addition on reverse side) <br /> 1 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 the following: <br /> "I certify that'in the performance"of`tlie: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 /> i <br /> Signed------- ----------------------- ----- - ------------` --=--- --Ownex <br /> BYl------ ----------- -- - - -----.+�:_.. . _. ............. <br /> .` <br /> ------Title-- --- i <br /> t (If other than owner) ' <br /> FOR-DEPARTMENT USE ONLY17 " <br /> APPLICATION ACCEPTEQ BY_ - __ __ ------- <br /> 1 --- -------- ------ DATE. ` g <br /> DIVISION OF,LAND NUMBER,_.--- ---- ------------------------- ----- -- -------...----------------------- DATE.---------- ------------------ <br /> ADDITIONALCOMMENTS------------------ ---------- ------------------------------- ---------------------------------------------------------------------------------------- ------------ <br /> ----------------------- <br /> ----- --- <br /> -- ---------------- --------------------------------------------------------------------------------- ------------------------- •------------------------------- ---------- <br /> ---------------------------------- --------- = - - <br /> Final-Inspection,by.--'. �� - Date....----. -_� <br /> P <br /> EH 11 24 SA JOAQUIN LOCAL HEALTH DISTRICT f&5 21677 REV, 7/76 3M <br />