Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> a APPLICATION FOR SANITATION PERMIT J -' <br /> r {Complete in Triplicate} Permit Na... ......... . <br /> ..................................... ................... <br /> Date Issued_S� .q.. <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 /> i <br /> _CENSUS TRACT....----- ....... . ...... <br /> JOB_ ADDRESS/LOCATION. 1.--7... .... �.. . <br /> i ���—o� <br /> Owner's Nam ............... - ----- .... :.. :.... ........................ . ..---... ...-------- Phone-..---- .!? '� <br /> ------. .IYaO ----- 4.f.:-� .-.... City"' Zip ------------ <br /> Address / <br /> t--Contractor's Name.-----.------.--...--./(1 License #:. 3 -gI---.-..Phone. ---��/...... <br /> i F- i ------. -.J------------------------ -.. <br /> F , ­­ <br /> Installation will serve: Residence (-Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other; :..:. "' "'`- =-L--.'--.--------- 7­ <br /> N <br /> Number of living units:....-. ------Number of bedrooms... ,- ,Garbage Grinder ....Lot Size.&Q )(/430 e <br /> 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.. -;_ . ...If yes, type----------_-------- <br /> (Plot <br /> ......-.-_........(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed ori reverse side.) r <br /> NEW ,INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,[ �1C. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ( ] Size----------------------------- ----- ------Liquid Depth..........................Cj <br /> Ca P Y acit ...t Material--------------- ,----No. Compartments......---------------- <br /> ------------ <br /> . Type <br /> Distance'to nearest: Well------------.------......................:..Foundation.......---.. ......... .. Prop. Line-.-.._..-------...... <br /> . -... <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: �Welf--- "'---.•------- --------Foundation.----------•-----------..-..Property Line-------_-•------------------•...--- <br /> SEEPAGE PIT [ ] Depth..---_......'..Diameter....._ .--T--..--.Number._:--;---=--------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth.-..-?......... .................... ------------- Size <br /> Distance to nearest: Well----_-----------------~--------- ------Foundation----------- .---.--.Prop. Line----------- •.--- <br /> REPAIR/ADDITION (Prev. Sanitation Permit-.#.............`".�Y-------- --------- <br /> i (Specify / ------------Date_--.---:•.-.-.- <br /> -=-•--- - --------- --------------- <br /> Septic <br /> ----- <br /> Se tit Tank Re uirementsl- -- ... } <br /> ot <br /> Disposal Field (Specify Requirements) ,(... .. .. ------- -------- ' <br /> -------------- <br /> --­----------------- _1----------------------- <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, 1 shall not employ any person in such manner as <br /> to become subject torl m ns (C-omtsensatf'on laws of California." s <br /> I - Owner <br /> Signed..---- - - T ...: <br /> By............---------- <br /> Title <br /> (Ef other than owner) <br /> T- 7 <br /> PART NT USE ONLY <br /> --- ------DATE.- <br /> APPLICATION ACCEPTED BY- . . - <br /> DIVISION OF LAND NUMBER ..._. ...DATE.......-- ......................----...... <br /> ADDITICzNAL COMMENTS_. .... 1 - - - <br /> ...------- -• .......... <br /> Final ------------------ --------------- ---- - <br /> Final <br /> Inspection b � ----------------------------Date.-.- <br /> � F8 21b77 REV. 7/7b 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />