71-887 - Laserfiche WebLink

Home Browse Search

FOR OFFICE,USE: APPLICATION FOR SANITATION PERMIT rI p -- --------------------------------------- ------- t • Permit No. .�-l-----d-1 / (Complete in Triplicate) I Date Issued 1--_2_Y_J/ I ------------------------------ -------------- �7 This Permit Expires 1 Year From Date Issued - / Z •i Application is hereby made to t um Local Health District for a permit to construct and install the work herein described. This application is lance with County Or inanee No. 549 an "existing Rules and Regulations: P ., �r ,I - .l ---- ---,---L�----;------------ --- - '----..CENSUS TRACT -------------------------- Owner's -------------- f JOB ADDRESS/LOCATI ____ _ _ --------•• Owner's Name - --- ----c___.____-- - Phonee �_'_rX_�_7_.6e� Address = -------C - -K--------. City, Contractor's Name __ ------ Installation Phone _7-_ °-`�a _�� �� - ----- ---.License # _ sZ � Installation will serve: Residence [:i�partment House❑ Commercial :❑Trailer Court ',❑ Motel ❑ Other -------------------------------------------- Number of living units:.... Number of bedrooms ______Garbage Grinder _.__ ------- Lot Size - -- Water Supply: Public System and name -------------------------------------------------------------------- ----------------------- ------------Privatex Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam a Hardpan ❑ Adobe'❑- Fill Material ------------Iif yes,type ---------------------------- , (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) (y NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ J Size----------------------------------------------i Liquid Depth -----------------------.-- Capacity --- TYPe -------------------- Material---------------------- NoT Compartments ------- =—Distance to ,nearest: Well ------------------------------------Foundation --------------------- Prop. Line ----------------------- i LEACHING LINE [ ] I^-No`°of•Liries --------------.Length of each line----------------------------- Total Length -----------_---------------- �t -'Di Box ------------- Type Filter Material --------------------Depth Filter Material ----_--_--------------------------•--_------ �a , Distance to nearest: Well __________._ --------------'`- Property t „ ------___--- Foundation Proper Line ------------------------ SEEPAGE PIT4 ]; - "Depth - --------- Diameter ________________ Number ---------------�'F------.___ Rock Filled Yes ❑ No i❑ w . . r ,Nater, Table Depth ------------------------------------------------Rock Size -------------------------------- Distance -------------------------------Distance to nearest: Well ------------------------------_---------Foundation ------ ------------- Prop. Line ...._____.____._____-_ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------------------__-� Septic Tank (Specify Requirements) - ---------, ----- --- ------- k Disposal Field {Specify Requirements) -- / - ------------- -- ------------------------ - � i - ____ (Draw existing and required addition on reverse side) I hereby certify that I have 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 licen- sed agents signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner a as to become subie t to Mork an's pen3ation la of California." pip Signed -- -- Owner BY ---------------- ------------------------------- -------- Title -------------- ----- -------------------- --------------------------- (If other than owner) F ARTMENT USE ONLY APPLICATION ACCEPTED BY .-- -- ----- --- - -- -------------------------------------------------- DATE ------- BUILDING PERMIT ISSUED --- ---- --- --------------------------DATE ---------------------- ADDITIONALCOMMENTS - ----- - ---------------------------------------------------------------------------- -------- - ---------------- ----------------------------------------- --- - --- ------` -------------------------------------------------------- ---------------------- --------- ---------- ------ Final Inspection by: ----- ----- - ----------------Date - ` ` A JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'6 ev. 5M