Laserfiche WebLink
FOF- ---------------R OFFICE USE: I FOR OFFICE USE <br /> APPLICATION FOR SANITATION PERMIT : <br /> (Complete in Triplicate) Permit No....... _q Z <br /> f - <br /> This Permit Expires 1 Year From Date Issued Date Issued._ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to 3construct and install the work herein described. <br /> his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATION.. <br /> .... .. ------.CENSUS TRACT.................. <br /> Fwner's Nam? <br /> am ... .... ... .. . _•'! ' ... ............ Phone..�4. <br /> .. 3" � � .... <br /> cldress ' '..%�'f�__��"' 1 Cit ..- Zi <br /> Y .... p-- ................ <br /> F Contractor's Name.-- ... . --- --- ------ - --------License Phone.'f...,!v..s..- v�La..._.. <br /> n <br /> FF <br /> Fstallation will serve: Residence E]Apartment House ❑ Commercial Trailer Court ❑ <br /> i <br /> Motel ❑ Other_...... .. <br /> umber of living units:_.X....._Nu l ber of bedrooms..a'.�-_ .Garbage Grinde,r............Lot Size.. <br /> Nater Supply: Public System and name................. Private' <br /> Character of sail to a de th of 3 feet; Sand Silt Cla <br /> P ❑ ❑ y ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑� Adobe 9 Fill Material............If yes, type................I_ . ._........ <br /> ('Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> rJ <br /> EW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r <br /> i <br /> PACKAGE TREATMENT <br /> - SEPTIC [ l Size ----- -------- <br /> .... C <br /> - - --- Liquid Depth... .. ......... .r <br /> Capacity ...:FL.......-- . Type--- ...... Material--------- ..........No. Compartments------------ --------- ........... <br /> Distance to 'I Barest: Well............ ....... .......... ... ......Foundation....... .... ...... ......Prop, Line.....................-.. - " <br /> i EACHING LINE [ ] No. of Lines.............................Length of each line----------------- .. Total Length . <br /> D' Box.... _. --Type Filter Material-.-- ........Depth Filter Material........................................ <br /> r Distance,to nearest: Well------------------ .. .. <br /> Foundation_----.-----..-.-----.- _..Property Line--_.___-------.---.........•I <br /> SEEPAGE PIT [ ] Depth-_--......'I._...Diameter------._.__. ------Number--- ---------------------------- Rock Filled Yes E] No❑ <br /> WaterTable Depth---------- ------------------------------------ ---..-.Rock Size................................................ <br /> Distance to `earest: Well__........_ - --------Foundation.-_.._._....-------------Prop, Line-------_____._....... <br /> EPAIR/ADDITION [Prev. Sanitation Per t#--- --------------------- ---------------,--.-Date.---- -- ......-.------ ) <br /> ------------ <br /> Septic lank (Specify Requirements).-..'L.[�9 .- 4 hc - .i. -� <br /> � .....--- wl �ljDisposal Field (Specify Requirementsl- Via` --•�•----- " -------- <br /> �... _ - . . <br /> --------------- ..................... ... <br /> -- --- --- - ----------------------•---------------------- F <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared) this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rule4 and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> Sig <br /> nature certifies the following: 'I <br /> 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 /> rt,011 <br /> become subject ark en'sompation laws of California." I° <br /> igned----- ----- -- ----OWnE*r <br /> i <br /> s <br /> ABY ' . _.:'.......Title.............. ------------------------------ <br /> (If other thar owner) <br /> I FOR DEP RTMENT S ONLY <br /> �' rs <br /> -APPLICATION ACCEPTED BY I . f.-__ _'_ .... .a+`" .- DATE <br /> ____ __ <br /> DIVISION OF LAND NUMBER.............:. <br /> .............. ....:........---.._r_..-- - - -------- --------- ---.DATE.--- --- ........---- <br /> ADDITIONAL COMMENTS... ---- ------------- - ----_-- ------------ ------------- --------- .... <br /> . . . ---- . . .....------. ---- -----------------------1_11____1------------------------- ....------ . --- ........... <br /> F...................... .__.......................... . ................----------------------------:-------- ------ I <br /> I <br /> ....... ---------- ----------- - ------­----------------------- - . ................................ .­ ...... <br /> Final Inspection by: - ---------- ------------------ --—........................ --.....Date ------ <br /> F --------------- --------------------------- <br /> �. <br /> EH 13 24 3I / /7� F&S 21h77 REV. 7/76 3M <br /> SAN JOAQUIN LOCAs HEALTH DISTRICT <br />