Laserfiche WebLink
FOR.OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ,. r.' L Permit No. <br /> �=--- - ---------------------------------- _ _ <br /> - {Complete in Triplicate} <br /> This Permit Expires 1 Year From bate Issued Date Issued <br /> _ <br /> ------------------------------------------ --_ _ <br /> ---- --- <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 ._- � Q ,� -rF---------/+P_Cf`-%---- --- --,CENSUS TRACT -------------- ----------- <br /> Owner's NameC_Z. c��/�------ ------ Phone ✓« <br /> CitAddress -------����-��-------------- - - _ Y -------------- -------------------------------- --------- --------------- <br /> Contractor's Name __. ` %11 -/ 1" ---License #/ _ Phone _ It <br /> i <br /> Installation will serve: Residence A Apartmerit House❑ Commerciat ❑Trailer Court i,❑ f <br /> Motel ❑Other ------------------------------ ------------- <br /> Number of living units:--- ------ Number of bedrooms --.-?-----Garbage Grinder -1 -+ -_ Lot Size ---------------- <br /> Water Supply: Public System and name ------------------------- ------•--------------------------------=------------------------------------------ -Private (91 <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam :❑ <br /> Hardpan ❑ Adobe J� 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,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK:( ] Size----------------------------------------- ---- Liquid Depth --------------------:----- <br /> Capacity Type -------------------- Material---------------------- No. Compartments -------------------•- <br /> ► Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------ --------- <br /> ------------ <br /> 'D' Box t _=--_____ Type Filter Material ---------------------Depth Filter Material --------------------------------------------- <br /> Distance to:,nearest: Well _______________________"Foundation ------------------------ Property Line. ------------------------- <br /> SEEPAGE PIT [ ] Depth ------ - :' 1:-:--,-� Diameter,_.-s --------Number ------- - =- <br /> --- ---- --- Rock Filled Yes F1No )❑ <br /> Water Table Depth { --------------------------Rock Size ------------------------------- <br /> -_ <br /> 4, <br /> Distance to nearest: Well `---------------------------------------Foundation ------------}------ Prop- Line _..--________.----__-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------_----------------.- Date ----------------------------•-----1 <br /> Septic Tank (Specify Requirements) ------------------ s ------------------------------------ -- --------------- -------- -------- -------- <br /> Disposal Field (Specify Requirements) ------ <br /> ----- , -� <br /> r�f ------a - 1 rr <br /> s.. <br /> / ------------------------ <br /> ----------- <br /> = -------- ----------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <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 Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following- <br /> "] <br /> ollowing:"1 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 /> k -------- <br /> -.�i_ � --------------�--- -------- Title -- ------------ -----•-------- <br /> (If � hanW <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -- ---------------------------- DATE _- ----- --�- -- <br /> BUILDING PERMIT ISSUED - -------------------- - -----DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------ ---------------- ------------------------------------------------ <br /> ------------- ---- <br /> - -- --------------------------------------- <br /> ------------ --------------------------------------------- -------------- <br /> -----------------------------------" f----------------------------------- <br /> - --------- ------------------ ------ -------------------- ----------------------------------------------- I� S� t- <br /> Final'Inspection by: . . ----- - ---------------------------------Date -/------------------1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> ' E. H. 9 1-'68 Rev. 5M <br />