Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------ <br /> Permit No: _--- - - --------- <br /> - <br /> (Complete in Triplicate) <br /> ------------------------------ <br /> _______________________________________________________ This Permit Expires 1 Year From Date Issued <br /> 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 /> JOB ADDRESS/LOCATION .-------3�----_...--�1�---- f�_`' - -------------------- <br /> --------- <br /> ------CENSUS TRACT -------------------------- <br /> Owner's Name --- % � - Phone ."'-C7 �� <br /> Address -- ------------- -------------------------- City -------------------------------------------- <br /> License Name -----14-1117_._/`-��ZLicense # ���� -.- Phone '- � <br /> ------------------------------- <br /> Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court <br /> Motel ❑Other -- ----------------------------------------- <br /> Number of living units:- /------- Number of bedroomsM,_:. - Garbage Grinder Lot Size ...._ ____________ <br /> Water Supply: Public System and name -------------------- -------------------------------------------------------------------------------Private <br /> i <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam <br /> 3 <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type ---------------------------- <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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Jf l! <br /> P� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---��-_/---X -------------------- Liquid Depth ----�T........-,_____ S <br /> Capacity __1aV`0--- Type - ~-_ aterial---------------------- No. Compartments <br /> r Distance to nearest: Well .--_--- ---------------------Foundation /,&!-----_-------_ Prop. Line ___ ...:-,_-_.-- rL <br /> • <br /> LEACHING LINE [ ] No. of Lines ---!;Z---------------- Length of each line.... Total Length -_—----_-. <br /> 'D' Box __/------- Type Filter Materi / Depth Filter Material ---- _' .______________________ <br /> > r )o <br /> Distance to nearest: Well -------- <br /> Foundation _.Q-------------- Property Line ---45_�-------------- <br /> ----- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C, <br /> ...Water Table Depth ------------------------------- Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------- -----Foundation -:------------------ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit x# -------------------------------------------- Date -_--_-__-_-----_--__-_---_-_--_---j <br /> Septic Tank (Specify Requirements) -------------------------------- ------------•--------------- •-•-----•-- <br /> !Disposal Field (Specify Requirements) -------------- ------- -- -------------- --------_------_---__--- <br /> - - ------------------------ ---------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------ <br /> ----------------------- <br /> x ----------------------------------------------------------- -=-q -----------� ------------------------------------ <br /> s ,�{ (Draw existingand re wired addition on reverse=side), <br /> 1 hereby certify that 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 Joaquin Lo a'Heaith District. Home owner or licen- <br /> sed agents signature certifies the'following:- _�� <br /> "I certify that-1n-the performance-of the work-for which ihls permit is,issued, I shall not employ any person in such manner <br /> as to become subject Wor man's rnperisation Laws of California." <br /> 1 <br /> S'sgned=-- ----- ----- ---- - ------------------------------------------- Owner <br /> (If other than owner) 3 f <br /> By --- ------ ` ------- 7it1e --------------------- --------------------- <br /> f <br /> ` r g`"µ - FOR•DEPARTMENT USE ONLY <br /> APPLICATION! ACCEPTED BY -.-- __-- _ DATE ------- - -- S-_____.__---. <br /> BUILDING PERMIT ISSUED ---- 5 ?-------------------------- ------- -- ----•------------------------=--------------DATE <br /> ADDITIONAL COMMENTS ''`--------------------- ------------------------- ---------------------------------- <br /> ----------------------------------------------------------------------------------- <br /> - <br /> -1� --1.. -_ - --- i. <br /> �, <br /> ------------------- ------ -- ---------- <br /> _ -- <br /> - r 1 <br /> Final Inspection by: --------------- ----- ------------------------------------------------------------------Date-------kk=--$." --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r; <br /> E. H. 9 1-'68 Rev. 5M <br />