Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT x <br /> --•--------='----------------- ------- ------ P G <br /> (Complete in Triplicate) Permit No....Tf�".......___ <br /> Date Issued....'.__.. _...,% <br /> -•----•-------------------------------------------------- J 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._.-.- K <br /> . --.-- •------. ........... . ..... ------..CENSUS TRACT...... ......... ............ <br /> Owner's Name.---TA ------------ ----- Phone..........................•---•------- - <br /> Address-- --------- City• .C .F � Zip---------- ---- -- --- <br /> -- , . .... oContractor's Name_ ___.___ License # ---.__._.--------. Phn -- <br /> _. <br /> Installation <br /> will serve: Residence') Apartment House ❑ Commercial ❑ Trailer Court ❑ r_- <br /> Motel <br /> Motel ❑ Other---..------ . -•-•---•-------------• f � <br /> Number of living units:...../.......Number of bedr __...garbage Grinder/��?__Lot Size c; _.__... .� <br /> Water Supply: Public System and name-- ------ 0-- . ........... --------------- ..----Private [h_ <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 /> X <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 -.Liquid Depth..:. -. <br /> [ ] . Size - -- -- ---...----•-•------------------ - ---- -- <br /> Capacity_... _---- ----.---Type..........:.. .. .. Material.----------- ......... ---No. Compartments-------_-----_ -- <br /> Distance to nearest: Well.......... ------I-------.-.,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-- ------ . . _.----...I.._-----...----- <br /> Distance to nearest: Well.-..-------------___-------------------Foundation---_------------------..Prop. Line..-_------..__.___--------- <br /> REPAIR/ADDITION (Prev. Sanitation Per it .Date -. ---.-----) <br /> Septic Tank (Specify Requirements)._._ __.. ...�� �. � ��:-__ !�+��. � �,,�.��'c�j <br /> Disposal Field (Specify Requirements).. .......... . .....-- ---....................... -•------ ----- - ----------------------------------- <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 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 subject to,,Workman's Compensation laws of California." <br /> Signed--- ;r°" -. _,... f ::_Owner <br /> By..------.... .. .__..Title <br /> ------------ ----- <br /> (If other thner) <br /> FO DEPARTMENT US&ONLY <br /> APPLICATION ACCEPTED BY------. .. - --- - ---"---" ...........................DATE .--- �� ... <br /> DIVISION OF LAND NUMBER.----- -- . . .. . .. ---- - ------r - l DATE------- ------- -- ---- -- ----------- ---- <br /> ADDITIONAL COMMENTS -•--------- ` 33 !� x Z7f } <br /> ------------- <br /> --------------------- ------ ------ ---------- . .. <br /> --------------------------------------- --- <br /> ....------•------- ........ r ---- - ----- -- <br /> Final Inspection by:.-.---- - ------ -- Date ft �� <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&S 21677 REV. 7/76 3M <br />