Laserfiche WebLink
FOR OFFICE USE: '-' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - -------------------------------=----------------- 4 �� <br /> (Complete in Triplicate) Permit o..._____________------ , <br /> ----------- ---------------------------- <br /> aZa 7 <br /> Date <br /> ----------- <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 /> 108 ADDRESS/LOCATION. IvI� R ` ------------ ----------CENSUS TRACT <br /> t <br /> Owner's Name - - ------ - ------Phone - ---------- ------------ <br /> Address - / tY-. ------ ip <br /> k 'Ci Z <br /> Contractor's Name----- ----- -- ----- --- - L License #---Mef-- 2_4: Phone---------------------------------- <br /> Installation <br /> --- -------- ----------Installation will. serve: ^yA Residence �Apartment,House.❑ ''Commercial F] Trailer Court E] � <br /> �— , `'`Motel'❑�tOther t - ' <br /> Number of living units Js .. of bedrooms___._ Garbage Grinder .--: -.Lot Size - _.----_-_-. _ _-___._. <br /> Water Supply: Public System Viand name--------------------------------=-------------- --- ------_.- ---_-----.-' .: --------------------------------Private <br /> Character of soil.to a depth of 3 feet: - Sand El 'Silt LJ -Clay E] Peat EJSandy Loam E] Clay Loam [>� <br /> - Hardpan ❑ Adobe ❑ " Fill Material__ __:_____If yes, type--- ---------------------------- <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings,'etc- must be:placed on reverse side.) <br /> NEW INSTALLATION: ':(Nb­s'eptic tank or see age ,pit permitted if public sewer is available within 200 feet,] <br /> I? PACKAGE-TREATMENT ['] G SEPTIC TANK '[7 Size'✓ t `p__._s _:✓ ______________________Liquid Depth ._ ----------------------IlkN <br /> : Capacity-�lFQ4� Type- _ Material----�CI -C.----No. Compartments------ ------------------------ <br /> r . --- ---Foundation ........... Prop. Line_.-__XL� - <br /> I' <br /> l .. . . .Distance to riearest:rWell_:---- _-�' �•;:-- - -- <br /> LEACHING LINE [!'rMNo,_of Lines__ _ <br /> __ __ _ Length ofeach line.--' _ .__- f <br /> Total Length.__. _. rQ "_ <br /> I ` 'D' Box.--- Type nklte-Fr ci a ail"-"�`- �� �__`_ Depth Filter Material Q"r------------------------------------ ----- <br /> Distance <br /> ---Distance.to nearest: Well-'__ l�_ `_._y_ __Foundat.ion.___.f__C�-_�._--.---.Proper.ty Line__._ S" v ---------- <br /> De <br /> -_ <br /> _ / ' - <br /> [ Depth---- ,3Lr" r z_-. -.__Number---=------.��---------------- <br /> s ; Rock Filled ;Yes No <br /> El <br /> Water-Table_Depth----- --` :° ---------------------- ----Rock Size------f / -----'r- --------,--------- 3 <br /> ` Distance to nearest: Well r "____.____.Foundation-`_---JV <br /> -_ -_--Prop. Line----- <br /> i <br /> �___ <br /> F ; ---------i <br /> r REPAIR/ADDITION (Preva Sariitatian�Permit#_-____-ti __:_ ___:>'^ -_______________FDate--.----_----'- f <br /> ------------------------ <br /> SepticTank [Specify Requirements)-f ---------------------------------=--=-=- -------------------- - --- , ----'---------------------=-------------------- <br /> Disposal Field {Specify R''eqvirements]: -------------- --------- ------------•------- f <br /> ------------------------------------------------------ <br /> t ` ----------------------- ------------------=--------- <br /> (Draw existing and required addition.on reverse side) i L <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 thdt in.the performance"of the work for which this permit1 issued, I shall not employ an_y person in such manner-as <br /> to become .subject to. Workman's'Compensation- laws of. California.'.,' <br /> Signed---- -- ------ ----------------------- . . <br /> -- - - - - --- -- - - ----- Owner <br /> b- _ t .. __ ---- - --- ------------------------- k <br /> F <br /> By <br /> ' <br /> '• d (If other than owner) l <br /> } "--'"" ", " ' FOR DEPARTMENT USE ONLY <br /> ¢ ,T s t . .. .. 7 <br /> APPLICATION ACCEPTED BY----- = = = = = " DATE. <br /> ` D1V1510N OF LAND NUMBER------------L------ --------------------------------------- ----.------ -------DATE E-------- = ------------- <br /> ADDITIONAL COMMENTS F <br /> ------------------------------------------------------=--- % -----------------------------= -=----- <br /> ------------ -------------------------------------- - _ <br /> -- <br /> Final Inspection-b �� I <br /> - bate -=�----"-'= - - -- - <br /> EH 13 24 . SAN OAQUIN L CAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />