78-314 - Laserfiche WebLink

Home Browse Search

�. FOR OFFICE USE: •FOR`OFFICE USE: APPLICATION FOR SANITATION PERMIT y - (Complete in Triplicate) Permit ............ -------------- Date lssued__`'� - 6--7 .....................................................:.. This Permit Expires 1 Year From Date Issued Application is hereby made to.the San Joaquin Local Health District for a per.mit�to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and exisfiqg Rules and Regulations: JOB ADDRESS/LO TION.. . .�.1 / n ----...CENSUS TRACT'....... Owner's Name -- • , A'-�f� -------.._.Phone /: .._. .-...... Address : ..��.. .�`�� /� CPl 17 City .-... ?a?7L�......... Zip .. x t; w . Contractor's Name.---- �� ................... License #_._-------.----- Phone.`.. - 1 Installation will serve: Residence V Apartment House ❑ Commercial ❑ Trailer Court❑ Motel ❑ Other-- .. ... . Number of living units:..-J..........Number of bedrooms.-,?.. _Garbage Grinder---..-----.-Lot Size----- -------. l - s Water Supply: Public System and name. ----------- ------------ - ...... .---------------- ------------ ---• .....Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ !'Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ kAdobe Fill Material.. ..-- .._.If yes, type----:------------- --------- - - [ , [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse:side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size - --� .---.----------------------- ------Liquid Depth.--- T Capacity-J2, 0-. . ------------- - - Matarial._. E1= o. Compartments..- a?:........... ............ J Distance to nearest: WelL...... ....................Foundation.-------.. . ............ Prop. Line.............--.-..----- LEACHING LINE [ ] No. of Lines . . ..".-.Length of each line.- --.. ........... ...,Total Length ength ..�1 . -- ------------- 'D' Box.....I- Type Filter Material-C.O.h.f-Atf4pth Filter MateriaL..4s......... ________-----.•-.-- ------ Distance to nearest: Well.... _• ...:...--....Foundation----------------------------Property Line.------------------------ . SEEPAGE PIT [ ] Depth_. Number____ _______________"__---------------------- Rock Filled Yes 0 No Water Table Depth------------------------------------------------------------Rock-Size------- ------- -- v i Distance to nearest: Well.. --------------------------Foundation----- ----- ..- Prop. Line---------...------------- REPAIR/ADDITION (Prev. Sanitation Permit#."................. ...... Date. ) Septic Tank (Specify Requirements] ------------- ' Disposal Field (Specify Requirements)_!, ----------- - ------------------------------------_------- -------------- f ------------------------------------------------ -------- --- - - --......---------------------------------------- (Draw existing and required addition on reverse side] I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County R' Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: r "I certify that ' the per-forma ce of the work for which this permit is issued, I shalt not employ any person in such manner as to becom s ect to Work n's Compensation laws of California." Signed.}(.-- --- ---- -- - -------- ------------ ------ --Owner BY.................... ............. .... ................................ .........Title----------- ....--------.......--- .....---...... :--------- ...... ( f ther than owner) F R DE ARTMENT USE ONLY APPLICATION ACCEPTED BY_.__.--.-.--- . . ---- ----. -DATE ...--....... .... -- -------- --- DIVISION OF LAND NUMBER--------------- --- ........... -------- .......-- ---.....DATE.------ -- -------.--- _- ---- ............. ADDITIONAL COMMENTS............. --- ----------- t -•-•- --------------• ---------------------- ------ -- ` � 1 17 ------------- --------------- ---..rP�.=.. _ -----•.---- -----•--- ------ ----.................-------------------- --- ------ - ---------------• _.-----.--------.--- ....- - ---- ....................... ------------------------- .- - Y----------- ---------- --- == Final InspecnohA:?y; -- ....Dater----L _.23 7 -------- ,A' .._".. EH 13 24 .. SAN JOAQUIN LOCAL HEALTH D RIOT F&S 21677 REv. 7/76 3M