Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: <br /> .,PPLICATION FOR SANITATION PERMIT <br /> ------------------ rr,, <br /> Permit No.._7`1_-..JeG.d <br /> (Complete in Triplicate) <br /> Date Issued �'Pf_/- 7q- <br /> ----------------------___...__._-____._ - This Permit Expires 1 Year From Date Issued <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO ----------- ---- *.L..lG_.�f "� ----'----------------CENSUS TRACT ---------------_------- --- - <br /> ,vner's Name - - s!Z- --------- ----,---------------------------------------------------------Phone----- --------- --------------------- <br /> Address--- ---------v:�---1.7 - --/.`-l�� > �r� A City---- ---- --------zip.....+ s- ------- <br /> )ntractor's Name------- ."' 044.."g !` " 7R`--�D------------License #---3,28Z"___.---Phone.----------------------------- -- <br /> stallation will serve: Residence ❑ Apartment House ❑ Commeoial ❑ Trailer Court ❑ <br /> Motel ❑ Other. AoW.-4— <br /> .)mber of living units:.----t -------Number of bedrooms._,,,,S----Garbage Grinder------------Lot Size -------3 a__G___.�'._C_ -A-_-Q________________ <br /> v,'ater Supply: Public System and name------------ ----- -------------------------------- ------------------------------------------_--------------------------------Private <br /> f-haracter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat EJ Sandy Loam E] Clay Loam El <br /> Hardpan Z Adobe E] Fill Material.. ........-If yes, type_.__.__________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> EW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ACKAGE TREATMENT [ ] SEPTIC TANK [MI/ Size. ���_�._x..7-�--x •x-- <br /> ------------------Liquid Depth__'.._._ ----------A <br /> Capacity-144_0-------Type--- - ------ - Mate-rial-----.rl. �t'...------No. Compartments----- 1 ----------------- <br /> Distance <br /> ------Distance to nearest: Well.... X6 ------------ Foundation......./it..._----------Prop. Line___-A------------------- <br /> LEACHING LINE [ No. of Lines ----- of each line._____.4-d------------- <br /> ---Total Length ------J-.^2-Cp...___.____._..__.._ <br /> 'D' Box..... __..__Type Filter Material_____,sr..A....Depth Filter Material-..---- _________________________________________ <br /> i <br /> Distance to nearest: Well-------- _ ..______-Foundation---------ID__.-_.-------Property Line------- - ------ <br /> SEEPAGE PIT [ Jr Depth..L_S-I___Diameter.3.3._----- ---Number � � Rock Filled Yes [� No <br /> Water Table Depth------------)AL1 Rock Size.--- X 3 ------------------- <br /> Distance to nearest: Well----------I._C)C3__I-------___--------Foundation.__1 .....___._._-.Prop. Line___._____..__.____. <br /> EPAIR/ADDITION (Prev. Sanitation Permit#-----------------------------.----------------------Date.___-___.-.._..____.....__-------.---.---I <br /> epticTank (Specify Requirements)---------- ---- -------------------------- ------------------------------------------ -------------------------------------- - -----------_------------- <br /> Disposal Field (Specify Requirements)..___._-...____.__ ...--------------------------------------------------------------- ---------- ------ <br /> ------­----------------- <br /> --------------------------- --------------------- ----------- ---- ------------------------------------------------------- ------------------------------------------------------ ----------- <br /> ------------------------------- ---------------------------------------------------- ----------------------------------------------...--------------- ----------------------- - <br /> (Draw existing and required addition on reverse side) <br /> 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, I shall not employ any person in such manner as <br /> .o become subject to Workman's Compensation laws of California." <br /> - -- � - Owner <br /> Signed-------- -- -- ------ � -- <br /> +_...Title__ <br /> 6 "- ke <br /> 3Y------------------- - ------- -- ---------- <br /> (If <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY--------------------------------------------------------------------------- ---------------------- ....DATE ------------- - - ------------------- - - - <br /> DIVISION OF LAND NUMBER---------------------------------- -------------------------- --------------------- ------ <br /> --- ---- --------DATE.------------- --------------------- --- -- -- <br /> - - <br /> ADDITIONALCOMMENTS-------------------- ------------------------------------ ------------- -------------- --------....---- <br /> ---------- ----------------------- --- ---------------------------- --- -- _ ---------------------------- ------------- ---- ----.. <br /> -------------------------------------------------------- ----------- ------------ ----------------------------------------------------------------------------------- --- <br /> ------ - -- ---------------------------------- <br /> ---- <br /> ----- <br /> ---------------- <br /> Final Inspection bDate..- �---------------- ----- <br /> P Y - <br /> ----- 1--u <br /> --- - --- ------ - -- - --- -------- <br /> EH 13 24 SAN JIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />