Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � <br /> I <br /> .............. -_--- <br /> --•-----•-•-•----•-•-•-•------- Permit No. ..��.�`.'��._. <br /> (Complete In Triplicate) <br /> .....................:..... <br /> Dote issued <br /> -•......................................................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> described. This application is made in compliance with County.Ordinance No. 549 and existing Rules and Regulations: <br /> O <br /> � � �..__. "....�. .. f! -.....,..... ......................CENSUS TRACT .......................... <br /> JOB ADDRESS/LOCATI <br /> Owner's Name -.._- '�.s' -�- <br /> ,. .....G7. •.. .Phone ..,...... .................... <br /> � Oc <br /> Address . . ......-.. .... City . <br /> ................................... <br /> I Y <br /> Contractor's Name ...... .. ...........: -License # JAZM........ Phone .............................. <br /> Installation will serve:. Reside ce [ Apartment House J3 Commercial ❑Traller Court 0 <br /> Motel ❑Other ................:...................I....... <br /> Number of .living units:-... --- Number of bedrooms Garbage Grinder ............ Lot Size ........................................... <br /> Water Supply: Public System and name ...... --------------------------•--------.:........__.............._.._..................................Private <br /> F Character of soil to a depth of 3 feet: Sand n Silt Q Clay 0 Peat❑ Sandy Loom fl Clay Loam ❑ <br /> F <br /> Hardpan Adobe'Q Fill Material ......... if yes,type ........ ... ............ <br /> �i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: lNo septic tank or seepage pit ,permitted if/public sewer Is available within 200 feet, <br /> PACKAGE TREATMENT ' I ] SEPTIC TAMC 141 Size-. .... Liquid. Depth ..` .. ............... <br /> Capacity d-Type .. No. Compartments ....�............. <br /> Distance. to nearest: Well I.R.V..H._.. la• <br /> ....__. .........Foundation ...1..�.. ........... Pro Llne'�.� .... ........ <br /> IL <br /> -.. <br /> LEACHING LINE [ No. of Lines .......,�.............. Length of each line---..... �.�^...... Total Length ......... , <br /> V Box ............ Type Filter Materia) `� ...Depth Filter Material /. `l. <br /> ._.. ................................ <br /> Distance to nearest: Well .... _ Q ... Foundation ......la.. .... Property Line ...... ..... <br /> SEEPAGE PIT [+ Depth ...'-. - - Diarsieter .. __ .. Number ................. Rack Filled Yes 0" No ( ° <br /> Water Table Depth ..+ .....:............Rock Size yp:..X. <br /> Distance to nearest: Well I_ p__ ...........Foundation :./4?..} .... Prop: Line ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------- ....................:............ Date ..................................I <br /> SepticTank (Specify Requirements)- ------------ -•---- ........................................................................................................................... <br /> Disposal Field (Specify Requirements) -------------------- --------- --- ------------- -------------- ................................. ......_............................ <br /> i <br /> ...... <br /> -- . -- ------- ------ -------- <br /> . <br /> :_._. <br /> .......................................------------------------------------------------- ..........__ . ...:.........._.._..__ r <br /> (Draw'existing and required addition our ®verse side) <br /> u . ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaqula Local Health:District.-Home owner or. Ilcm <br /> sed agents signature certifies the following: <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 <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------ -------------------- ---------. ------- Owner <br /> fs/1Fs �cJ�� G►� .................. . <br /> (If other than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . - ---------- ... =--. DATE:.' .. .;_.. :.. . <br /> BUILD1 NG`PERMIT' ISSUED - --- ------ . -•---------•-------•----------------- --------••...................---DATE ..........._..._......................... <br /> ADDITIONAL COMMENTS -------------------- - ................. <br /> - -----------------------'-------------------------...-. -----•--•---•---- .... -- ----------------------------- ---- ...... ---. ...--- •.....__..:.. <br /> ------------­­................... .. . ----------------------------------------=-------------------------- ..........I----------------- <br /> Final Inspection b ______ ___________________________Date . - '-. <br /> •............... <br /> EH 13 .21 1-66 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT;' 8/74 3M <br /> F <br />