Laserfiche WebLink
FOR GFFICE 'USE: FOR OFFICE USE: <br /> t APPLICATION FOR SANITATION PERMIT •� <br /> • ', .(Complete in Triplicate) Permit 'No. <br /> ------------------,4................................. •----- <br /> ........... This Permit Expire;Y�Y at From Date Issued Date <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> k This application is made in compliance.with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/.LOCATION. .d/&�,�7d.:. Q-N. :G /1l_. _.....---= _-----:.,.-.,-...CENSUS TRACT........... ..... --- <br /> r r Phone -` t <br /> Owners Name.... . �,-.-��Gu.L:i�..--.... <br /> Address------ ---------- -- - - �.� ....--..... % iC-?G Zi <br /> City p - ..-.. <br /> � s f <br /> �, +a Phone.. <br /> Contractor's'Name........... .. . License #-- --� - <br /> Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_-`� - -ILc:=z................. d G <br /> Number of living units-----------------Number of bedrooms..-.."__ .. Garbage Grinder-- _--..Lot Size:--.--- ...... ..._ <br /> Water Supply: Public System and namle ---------------- <br /> ham. ........ . .......... "-.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-.-.-.-. ....................... t' <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,) C' <br /> PACKAGE TREATMENT ( ] SEPTIC TANK ( ] Size..... -Y.5�--X5....... . ................Liquid Depth..- .......... <br /> Capacity..�A--------Type.�� X05 Material................. .......:No, Compartments---.-- -.}-. <br /> LEACHING L , f/ _ �� <br />[ Distance to nearest: Well--:-- Q -----------------_...._...Foundation-..��,. _..... ."... Prop. Line-.-----.-- ------- ......... <br /> INE ( ] No. of Lines_.(. -. - � <br /> 0,F <br /> � <br /> '� ---------------Length of each line.--�---.... -=------- - -Tatal Length ....f.�.--�..----�--- - - ---•-- <br /> f <br /> f 'D' Box.).. ....JType Filter pth Filter Mater al-----------------------------•--•-..----------------- ..-----"- <br /> Distance,,to nearest: Well. /,41'�-_?.� .....-"--.Foundation.--3767-.------"----"Property Line...- .:...................... <br /> SEEPAGE PIT p -...l.` � Rock Filled Yes No <br /> ( ] Depth. ---..D�ameter:'^-.-.z-------------Number,:=---------------------... -.-. ❑ ❑ <br /> Water Table "Depth....................... ....-----•. ...-.Rack Size.-.... - <br /> Distance to nearest: Well-------------------------------------------Foundation-----...... ..............Prop. Line..-...-...----. ------ - -. <br /> I <br />! REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------ ---.....-------Date---.----:--. ------------- ------------..-----) <br /> Septic Tank (Specify Requirements)..'-) --- --------=- -----...- ...... <br /> Disposal Field (Specify Requirements)• .........: -------•------------------------•-• --•---------- -------- ---- .................... <br /> N. <br /> -----•--------------------- ------ --------.-....- +------ - ------------------------------------------- - ............................ <br /> ------- <br /> (Draw existingand 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,f State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signs .ure certifies the following: + <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 /> «—I s <br /> to become subject f 7kman' Compensation laws of Califdrnia." <br /> Signed----... � ...f. ....''� . . . ------. --"--------------- Owner <br /> r <br /> BY .- Title..-....- <br /> ]If <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> r APPLICATION ACCEPTEDBY ................ DATE .. ...."7 ........... <br /> DIVISION OF LAND NUMBER: _ =' — r.._.. _ . __. �" ,- --DATE <br /> ADDITIONALCOMMENTS........... -------------------------------------- ---------------------------- "------------------------- - ..................... <br /> .....__ ..............�..-...-.---------.-....-- ... - -- ------- --------- - .--- <br /> f ....-........................................................�__..-.-...-......-_...-.-- --. .- .-.._--.----.......----.•-. - <br /> v ..-.._-- <br /> ( .-. -...._. <br /> Final lnspecr�on by:.......... x - Rate...-- <br /> - --------- -- -- <br /> Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT &S 21677 REV. 7/76 3M <br /> L � <br />