78-167 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: FOR OFFICE USE: ,. APPLICATION FOR SANITATION PERMIT ------------------------------------- ------------------ ` (CComplete,.in•Triplicate Perm ii No,__ �. -�_----------------------------- V .. _ Date Issued �.._.._�_�� Thi;-Permit Expires 1 Year From•Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliahce with_Covnty Ordinance No. 549 and existing Rules and Regulations: JOB AD LOCA N ,._" wi _ -- . _ ---------------- -- - -CENSUS TRACT.----- -- Owner's Name.:__,._ # r.4Y _. hone= Q��.--.-- Address Y Q ' -C�=t�-Pi - -- G City I Zip r-------------------------- ----------------------- Contractor , ----- -- nstallationsw II serve: " Residence Apartment House I Coni License _._ - -------------- Phone S' r p ❑ merdal ❑ Trai4er Cou t ❑ ;`�: s + Motel Other_______ ____ ____ / i Number of living units:__; Number of bedrooms--- --------Ga ba a Grinder..._._..._:_Lot Size__/vyf��______________ -- Water Supply: Public System and'name ± j { °, .:= Private ❑ i ------------------------------ Character of soil to a depth of 3 feet:; Sand ❑ Silt ❑ :Clay ❑ Peat 0 Sandy Loam4O 'Clay Loam ❑ { ] Hard an Adobe Fill Material__.._.__....If yes, type........ -- ------=------- [ (Plot plan, showing size of lot, location of7system in relation to-wells, buildings, etc. must be[placed"'on.reverse siclk) NEW INSTALLATION- `(No''septic tanfk or seepage ' pit permitted if public sewer is available]within5200 feet,] I i PACKAGE TREATMENT [ ] ~ SEPTIC TANK [.] Size------------------------------------------------------------Liquid Depth ----- --------------- { Capacity---------- -- ------Type:::_-____- _ F...M-aterial--- ------------------------No—C-ompartmehts . . .: Distance to nearest;.Well-=------------------------------ .. ._._._Foundation---------------------------Prop. Line.------ ..,. r i LEACHING LINE ['] No. of Lines----------------------- ------Lenqth of each line.__.____._'___.._ _-,.__ _,___Total Length .___,___.__.__ ._________- € .'D' Box--=--1--.-.-Type Filter Material-------- -=-----Depth Filter Material--------------------------------------------------------------- Distance to nearest: Well------- -----------'------Foundation---=------------------- --Property Line------------------------------- - SEEPAGE PIT [ ] Depth.__. !.'--------Diameter - -"-.Number__ """_""__ __-------- Rock Filled Yes ❑ No E] i Pt 7------ T ---- --------- -- ck Size--------------------------------------- --------- Water Tab a Depth'DI a th e ? _ Ro : Distahce`fd nearest: i •Wel�l _ :._ Fouedat' on- . - _ - _'Prop. Line----------------------- REPAIR/ADDITION -.---------" -- REPAFR%ADDITION (Prev., Sanitation Permit#______ _____________ _'_ _ ._______ .Dat - =� 1 Septic Tank JSpecify Re uqiremen`—s")�rte,. -- --- ��--�k - - -- -z�� -- _ ------------------- Disposal --- --------------Dis osal Field (Specify Requirements -- - -- .._---� ------ ------------------ •-- --------- --- - ----------------- -- ---------------------------------- --------------------- --- (Draw existing grid required addition on rteverse side) I hereby certify that-1 have prepared"this.appl cation and that the work will be. done in accordance with San Joaquin County Ordinances, State Laws, and Rules rand Redulations of- the San Joaquin Local Health' District, Home owner of licensed agents signature certifies the following: k r.__..F..._.._. i 4 "I certify that in the pei'formdnce of the work.for which this permit is issued,,I shall -not`e'mploy any person in.such manner as to becom> u ject fo Wo en's ( ompensoNon laws of California." aw Signed...:_ - --- -- - - --- ----- - - ------=---- ------ ---------- --Owner II p .. .. ; tiv .. .a --.Y-----�--- - ------ - _.. . ----- - ----Y Title------- -(If =(If other than owner} `i �-- - --• a I .FOR NLt DEPARTMENT USE OY- APPLICATION ACCEPTED BY ''_�,? - '=-------------------------- -----' DATE. J f. . .. T y r' ' DIVISION OF LAND NUMBS ------------ = - ------'-------------- ------ ----.DATE.:..---- = -- ADDITIONAL COMMENTS_.____ ------------- ------------------------------------ --------- - - -:-- . --. . ._... P y: = - --� Date S. ------ Fin'I Inspection b ----------------------------------- Fina EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT fes 21677 REV. Ina inn