Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------ Permit No,. _ fc <br /> {Complete in Triplicate} <br /> ------------------ _ �_t_ __� _-- This Permit Expires 1 Year From Date Issued <br /> Date Issued ___.-______._..___ <br /> Application is hereby made to the San Jo� in Local Health Distri. for a permit to construct and? install the work herein <br /> described. This application is made in co in <br /> a with County dedinance No. 549 and existing Rules and Regulations. <br /> Zr <br /> �7�, i <br /> JOB ADDRESS/LOCATION .__ c1.�S-- -- --------- } -------FF <br /> -------------------------CENSUS' TRACT _ _ - --_!__-_'-- <br /> oj ---------- -- -A E �� --------------------- --- ' <br /> Owner's Name ---- - -------- ------Phone --------------------••--- -•-------- - <br /> Address _ V VJr7i �l� -- CiSCf)L ------------------------•-------•----- <br /> 1 City <br /> 1 , <br /> Contractors Name 1; -- ------- <br /> ��--"-'--- /--------•-=-------.License # ------- -:------------- Phone _--------------------_---- <br /> Installation will serve: Res'i,Ctetice. p� ouse❑ Commercial l ❑Trailer Court <br /> tment H <br /> Motel ❑ Other J--------------------- r <br /> Number of liv" g units:---!__--_ Number of bedrootr�s _3------Garbage Grinder IN--- Lot Size __�J�_� -__..-_---fir._.. <br /> Water Supply: Public System and name- ---------------- ------------------------------------; Private ❑ <br /> haracter of soil to a depth of 3 feet: Sand'0 Silt E] Clay E] Peat ElSandy Loam ❑ lay Loam E] <br /> p ❑ - ❑ -- If yes, type-_,_____ <br /> ,i rd an Adobe Fill Material ____�.-___ <br /> (Plot plan,sfhoW!TT sizes LL of lot, location of system in relation to wells, buildings, etc. must be laced on reverse side.) N <br /> NEW INSTALLATION; <br /> (No septic tank <br /> --o--r- seepage <br /> ee a e pit permitted if public s <br /> ewer is available within <br /> 200 feet,) <br /> . f -PACKAGE TREATMENT SEPTIC Size------------------------------------------------ Liqui' pth -- <br /> ------------------------ <br /> -- <br /> Capacity <br /> Type ----------- --____-- Materiall--i-------------------- No. Comp <br /> artments ------.-----_---_---.--._ <br /> Distance to nWell- ------------------------------------Foundation ----------------------I Prop. Line ----_---------- <br /> - I <br /> LEACHING L r �! tlo � es_ '.``1*kL%6gt-.:'df each line- -- ---------------- . <br /> Length ------..-------------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material __-!---------------.---_--•--.------.------ <br /> i Distance to near s` Well ________________________ Foundation __________-_____--- ---- Property Line .___--_._--_____-_.....- <br /> SEEPAGE PIT [ Depth --------_.__I __�� Diameter _______:i_{____. Number --------------------- ------ <br /> RocklFilled Yes ❑ No 0a Water Table D t Rock Size <br /> 1 <br /> Distance to near st: Well ---------------------I-------------------Foundation _____ -�-r- --- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. <br /> ---------------------REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------I--------------- Date --------._----./s_\�___-_) <br /> r Septic Tank {Specify J2equirements} - --D157 ......-8-QK-----A----- - 1. .._ 5 � -.._--..-- �----------------- <br /> r ►t <br /> Disposal Field (Specify Requirements) __��------�-�-.._...�����----�_L.�Rc4.-i4N_A��-�, r--�_� PA1---------------- <br /> +f, 17_-]----`------ ----- -------- <br /> ---------- <br /> c- 1 F ------------------------------- <br /> [Draw existing and required addition on reverse side) <br /> ,�..� <br /> I hereby certify that I have�`p�epared this application and that the work i will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rule. and Regulations of the �an Joaquin Local Health Distri t. Home owner or licen- <br /> sed agents s' nature certifies �iie�follawing; <br /> "1 certify a int erfor n'�of the work`for which eh' permit is issued, I shall not employ any person in such manner <br /> as to bec a su a to an Compensation laves, Ca ifornia." <br /> Signed Q - ---- a Owner <br /> By ------------------------------------ -------------- ------------' '4 -----'-- Title ---- - <br /> {If other than owner) <br /> FOR DEPARTM NT USE ONLY <br /> APPLICATION ACCEPTED...BY .-----f 1-�-' --- -------------------------- ------------------ DATE •^ L <br /> BUILDFING-PERrM'iT-ISSUED -- w --_DATE -----------�'"�""�� <br /> ADDITIONAL COMMENTS ----- -- �, G I.N�_ _jz. n�_ <br /> __ _-_-_- <br /> ---------------------------------- --- ------- 4C1_ [ _ - ---------:----------------------- -------------------------- <br /> �' --------------- - ---------- --- -- -- -------- -------- ------------------------------------------------------ - -- <br /> Final Ins p - ` ------------------------------------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />