Laserfiche WebLink
I. FOR OFFICE USE: FOR OFFICE U5E: <br /> APPLICATION FOR SANITATION PERMIT <br /> � ✓% <br /> (Complete in Triplicate) Permit No ..v...- ..../... <br /> r <br /> -------------------------................................ { <br /> Date Issued.317.'.26 <br /> ......•. -----•---------- ................. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the SanlJoaquin 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 /> JOB ADDRESS/LOCATION._ _ -� ---....-r .Cil'-.. C � CENSUS TRACT--------------------------- <br /> -- -------------------------------- ---- -- -- <br /> Owner's Name H "r` /J......x,J .. - 'c ---------- ------------- ................ .............Phone- <br /> Address__._ _Ls r/st ......Y. ._l�� v ._.i�dt...........................:......city--- ��'��`�y"`_---------------- --zip................ <br /> Contractor's Name_ . .....License #-------.-.-.----------.._. .Phone................................ <br /> ... <br /> Installation will-serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [ y <br /> Number of living units:-.. Num <br /> Motel ❑ Other - ------- . --_-------- <br /> g �.---------- ber of bedrooms-,3--....Garbage Grinder............Lot Size-..........4<..4'0641.. ----.----:---•....... ..... .. <br /> Water Supply: Public System and name................... .................................. ...........................Private Et <br /> Character of soil to a depth of 3 feet: . Sand ❑ Silt❑ Clay ❑ Peat ❑ Sand -Loam E] Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material-- ---- If yes, type--------------------------- - -- <br /> t <br /> {Plot plan, showing size of lot, locatiari of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seeps pit permitted if public sewer.is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size--------------------------------------------------...._ _--.Liquid Depth..-.:--..--- �fl <br /> Capacity.12-e?U_ .-....Type-----------------------MatesriaVlZaT/e_',,Qy ``_No. Compartments------Z -------_-------- <br /> I Prop. Line--�_ _. <br /> _. 'stance to nearest: Wel(.-. -��--------------------------------Foundation--- -�--- -..- <br /> r „ <br /> LEACHING LINE [ No. of Lines.'... ...______________Length of each line_.." Total—Length ......._. �l� <br /> 'D' Box ......Type Filter Material '_. ......Depth Filter Mater_ia1.-=.._ '..__`_,.-�1�........................_...___--- ....... <br /> Distance to nearest: Well...t�.Q.._.............Foundation--JO.e ___..___._.__.-.-Property Line_.. 1 . ................. <br /> z` ,. . A . --r-2 . <br /> SEEPAGE PIT [ Depth._...Z.`j .:._Diameter:." _ <br /> . '----_._._.Number--------- ---------------- -- Rock Filled. Yes No <br /> WaterTable Depth------------- ----•-------- - -------------_-__- ----Rock' J........-----------------------'----------- <br /> ` Distance to nearest: Well---------•-----.----------------------------Foundation-•---------. .:_..._ Prop,;'Line.........--.---------- -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------ ---------------Date-_..__..:-_....-..-------------------- .. .... <br /> i Septic Tank (Specify Requirements).......................................................... <br /> -� -- --- ......R........ •------ <br /> Disposal Field (Specify Requirements)d-- ---------'------------------- --•------ - --- --------------------- ------ . <br /> - r- <br /> ............._...-- -------------- - !! <br /> ------------------------------------------ ---- --- ------------------•----­­-------------------------------------------- --------------........ ...... --------------------- -- -- <br /> �(Draw existing and 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, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> t <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 /> to become subject to Workman's Compe ation f California." <br /> Signed'Z �� /I_ __ __ — —� Owner <br /> By....................................... ............ ' .. ---------------------------- .....--.... Title---................. --- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICAT ---- --------------- -----DATE _.. ....... --- ------ <br /> DIVISION IO.F LANDON ENUMBERc <br /> :.. . . - -1 ... <br /> ADDITIONAL COMMENTS __� Ag <br /> ... ;,. 1 <br /> ............ -------------:- -.. _-- ! .. -- ----' ---- ---. ;_ .. .. -- . . .. -- -- --- ---.------..--•-- -- .. <br /> ------- --------- ..... <br /> Final-Inspection by:--- i <br /> EH 13 24 SAN JOAQUIN LOCAL HC H.. DISTRICT : F&S 210 REV. 7/76 3M <br />