Laserfiche WebLink
FCi7 OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �_�� <br /> (Complete in Triplicate) Permit No.-------•--------- <br /> -------------- --------------------------- ----- --- Gr -- <br /> Date Issued _._--- -. <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 canstruct a,nd -install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and"Regulatibns *�\ <br /> d� CENSUSTRACT------; ------------------- <br /> ------ ------------- ------- <br /> JOB ADDRESS/LOCATIO <br /> ' <br /> Phone -------------------- <br /> -------t <br /> ---- <br /> Owner's Name------- City Zi ------------------------------ <br /> Address--------- #_p_ /71----------Phone:. ` :---- <br /> Contractor's Name---------- _ ---- -' License <br /> installation will serve: Residence Apartment House.[] Commercial ❑ Trailer Court ❑ . <br /> F• .. . > Motel ❑ ; Other- ------------------- -------------- ----- <br /> Number of living units:._-----------Number of bedrooms._..__.Garbage Grindex_____________Lot Size `}"' ---_ --/- ---__-- ------------- <br /> Water Supply: Public System and name ---------------------'------------------- <br /> Private El <br /> of soil to a depth of 3 feet: Sand 0 -Sil# ❑ Clay ❑ Peat ❑ Sandy Loam ❑ ; Clay Loam' <br /> tHardpan ❑ Adobe ❑ Fill Material___-_------If yes,type ___`-- ----------- --------- <br /> a <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,} a <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] j Size--- yy ----, -jp --'-------Liquid Depth_-Y------------------- <br /> 1 <br /> Ca acit f P_T Q e- -----Material--_- - -- - -------No. Compartments------ --------------------- <br /> r -Foundation- _ -----------Pro Line------- ------------- <br /> Distance +Tj F <br /> ,- to.nearest: Well='-- �-Len th of each line-._ <br /> a � P <br /> h- --- - - - - -- <br /> LINE, [,l No._of Lines----- ,--- } g = Total Length _ _._Tits ----------------------- <br /> LEACHING t t <br /> 'D' Box- -__.TYp a Filter Material___ _ Depth th Filter Material_______ _-----------49---------------------------.--�--- <br /> - f . { <br /> Distance to nearest: Well_--__ - :_ Foundation- --------------------_,�I,'roperty Line -_-- ---__-- <br /> . u � ...—�-�. -- � riled Y N <br /> SEEPAGE PIT [ ] Depth" ja-6 --Diameter_._-�3_- __-_; Number __ ------ __ _-_ Rock F' es o ❑ <br /> Water Table Depth.----: _. - -----:---Rock Size-------------- / <br /> p ---- -- <br /> r P <br /> Distance to nearest: Well��_ - - ` Foundation--------------------- ---Prop. Line--------------___"-- <br /> �,ly <br /> REPAIR/ADDITION (Prey:Sanitation Permit#-- -'`-------- -`--- - - Date---------_------------------------------- + <br /> z -- = +� -- <br /> Septic Tank (Specify Requirements)- ---------------I `--='---------S°---------------=-,.} ---------------------------------------------- ------------- <br /> N. _ ' `- ------------ i <br /> Disposal Field (Specify Requirements)------- ----- -�.: ---- , -- -- ----- ----=------ ------------- i <br /> ----- - i <br /> 1 <br /> _________________________________________________________________________..-__ -___-- --___ -------- ------- ___________________ -___-__-. y__ ------------ ------ <br /> (Draw existing and required^a'ddition 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 anRegulations of the, San;Joaqm <br /> uin Local Health District. Hoe owner or licensed agents <br /> d'' <br /> signature certifies the following: r f ) 1 <br /> '., <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 /> p �sation- laws of California." <br /> to become subject to Workman's Com en <br /> i Signed. :. <br /> .� �Ow <br /> T• <br /> ex <br /> BY i <br /> ------------------------------ <br /> le <br /> 1 (If other than .owner] .1 ; <br /> + . OR: EP.ARTMENT USE ONLY r <br /> r APPLICATION ACCEPTED BY- DATE ------------: C <br /> -------------------------- - - <br /> DIVISION OF LAND NUMBER- ---- <br /> DATE-,/ <br /> -: <br /> .2 'Q4 <br /> ., 1 ,� - - ---------------------- <br /> I ADDITIONAL COMMENTS-'-_'-_­- <br /> - <br /> OMMENTS---ti- _ -! .if 4 _ i <br /> - -- <br /> - -" -------- ------------ .. <br /> ti +-� <br /> ---- <br /> ------------------------------------------- ------------ <br /> -- <br /> .. -_ --__-______________________________________________________________________________"-- __ _------------- _- -__ <br /> D t <br /> ------------- <br /> Final-Inspection b _ - - ----------------------- ._ _.� _�e�.. - � <br /> Y=- <br /> EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT gas 21577 REV, 7176 inn <br />