79-34 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------- ------- ---------- -- (Complete in Triplicate) Permit No - -_ -------------------------- ---- ---- --- ----- a'i��,�, q Date Issued.)." _ This Permit Expires 1 Year From Date Issued { Application is hereby made to the San Jooquin_Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: s JOB ADDRESS/LOCATION--:- -, - ��--- ----W 2R�ti---- -- fi -- �� -CENSUS TRACT-------- --- -- --- v� s - - - ----------------------- ('� s Owner's Name.------. -�------ -- �t5V�ti1---- ----=------'-------------- ---- n - Phone__6�9 �G J-Z. i Address -------.-� --- - �-3.9._ ? /N�� .- -- -- -City J�-1 L 'v '` --Zip Y Contractor's Name ' ✓-F16f--e----'- ..k.._-__..-__------+ - ----------------------- License #. '�`� 3 7r 8. Phone_ r6J�g�� Instaila'tion will serve: Residence [ Apart ent House El Commercial E] } {Trailer Court F] %Number of living units:_______________Number of bedr oms. Other.I-a-r-b-a-ge _____ i i Motel' ❑ g _; -- Grinder-= Lot Size------------------ y - Water Supply: Public System and'narrie__71'.:---.----- ---------- - ---- ------ -.,,----- ----------------- ----Private 5a Character of soil to a depth of 3 feet: ' Sand C5�, Silt t❑ Clay ❑ ' Peat E] Sandy Loam E] Clay Loam ❑ E Hardpan ❑ Adobe ❑ Fill Material -----_-----if yes, type----------- ------------- --_--- (Plot plan, showing size of lot, location of system iri relat.on to wells, buildings, etc. must be placed on reverse side.) PACKA INSTALLATION: (No tank or seepage it permitted if public sewer is available within 200 feet,] � - _. '''� -----------------------------------------'------------Liquid Depth ---------- SEP' Yp GE TREATMENT I� _N [*� e--2f- Size-rMa#erial._ -� �^'_ __-No. Compartments_ _.___ i ------------------- CapacitytA Distance ta-nearest: Well ` --_--. -----------Foundation �'�}d Prop. erre _- _ '� z' ?O i r -- LEACHING LINE [ ] No. of Lines -_{;�� -----------------Length of each-line;---.__ _,-_-;-----------Total Length ------- Type ___.___ t Ypria - p ` :D' Box �''r �2 Chi ria) ---------------------------------- B. - ------ _ tic t T e Filte?MateDe th Filter Mate _ Distancato nearest: Wel!_:_.__ ;>`� `Foundation__., _____.__.____.Property Line. SEEPAGE PIT Depth.___'-----------D`iameter.? umber.-...__ __ _--- Rock Filled Yes.❑ No ❑ y _ i .., - - _ - ___ S Water Tabie�bepth----------= nEk_5ize ---------------------------------------' # .____.--Foundation'_______ ______ Distance.to nearesf: Well - rop. ine --------------- - - - REPAIR/ADDITION (Prev;.Sanitation Permit#_-:__._____ -Date------ _ ________________________-} -------------------------- Septic Tank !(Specify Requirements) -- ----------- ------------ --------' ------------ - -------------------- Disposal _Disposal Field (Specify Requirements)--------------------- � ---- --------------------------------- ----------------------- ----------------------------- ------------------------------ - ----------------- -- l .. _ a - -- -- ------- -- --------------------------------------------------------------- ----- ------ { '(Draw existing and required addition•on reverse side) I hereby certify that I haeme prepared this application and that•the-work-will be done. -in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: { "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 to become subject to Workman'.s. Cbmpensation:.laws of California." .. Signed ---------------Owner ._. f!.�� q. p.. ------ By-4 ----- --- ot------- -- = ------ --------- Title. = ! ------------------------ - - (If her Phan,bw e i" F R DEPARTMENT/Up ONLY APPLICATION ACCEPTED BY- = = ^ '.,`' ------ -- -------- '----------- -- DATE.. ° = F t DIVISION OF LAND NUMBER. ---------- ------- ----------: --- ---- ._DATE . .... _ ADDITIONAL COMMENTS--------------- ` - --------------------------- ---- ---------------------------------=--------------------------- ----- ------------- ------ ---------- --------------- t -------------------- ---- -- ----------------- Final Inspection by: .. .: ...�. — ---- - - -=--- --- ----_------ - --- --- _ :'--.Date.__ ---- 2� EH 13 24 SAN JOAQUIN OCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M "OW