69-495 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT // Permit No. ----------------------------------------- ----------- Com_ (Complete in Triplicate) � • ____-_..________________________.-_______-________-_-____ 1 J Date Issued.__-- ------- This lLThis 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 i described. This application- is made incompliance with County--Ordinance No'. 549 and-existing Rules and Regulations: JOB ADDRESS/LOCATIOi? l�I--lo -----------------CENSUS TRACT ---- ------------•-------- ` 'F----- Phone ! Owner's Name -- - - --� I---- ------------ city ----------------------------'--- Address ----I --------•----------------------•-•---•--•-•- - ---------------------f___ -- -- ---- + � _ � - 17 Contractor s'Name ___________ - - �� + License #l�05'W--__ Phone __ ._____ _ sf' I Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court ,'❑ F Motel ❑Other ------------------------------------ : ------- Number of livingunits-._.___J__ Number of bedrooms __-- Garbage Gri �e `_ '- _._ Lot SJe __ _ -- - -----• i Water Supply: Public System and!.name ----------------------- ---- - Private ❑ Character of.soil to a depth of-.1feet:- Sand'❑ Silt❑ CIayk)_j Peat❑ •Sandy Loam ❑ Cloy Loam [] Hardpan ❑ Adobe Fill Material _____-_ If yes,type------------------------- (Plot plan, showing size of lot, location of system in 'relafio^n-"to wells, Wildings, etc. must be placed on reverse side.) i NEW INSTALLATION: (No septic tank or seepage pit permitted T public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK [.] Size-------------".----------------------------------- Liquid Depth -------------------------- p Capacity ------ ----------- - Type ----------•--------- Material-------------- ------- No. Compartments -----------------•---- Distance to nearest: Well ------------------------------------Foundation ------------ ------ Prop. Line ---------- :--•-•.-. LEACHING LINE { ] No. of',Box -------- Lines --------------- ------- Length of each line.--------------------------- Total Length -------------------..--.---- D ) Type Filter Material ----------------- Filter Material --------------------.---_______. -.------- Distance to nearest: WeA---------------------- Fouridation ------------------------ Property Line ------------------- -- SEEPAGE PIT [ ) Depth --------- --------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0t WaterTable Depth -------------\---------------------------!---.Rock Size --------------------------••---- a -"- Distance tb nearest�Wello ___________________________ ____ Foundation --------- ------- Prop. Line _-_________..:__- ------ ---•- REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ----------------------------- Date ----------- _____ -------------) ` -- ------------- ------------ Septic Tank {Specify Requirements),, --- ------------------�---- ------ , �-�------------------- - Disposal Field (Specify Requirements) ------- - ------ - ----- --- " r----------- ----------------- - �y�Q' d"�- -``-► 7 ---- fQ ----•--------- kI { i *+ F (Draw existing and required addition on reverse side) I hereby certify that.l have prepared;this application and that the work will be done in accordance with San Joaquin County Ordinances; State Law's, acid Rules and Regulations of the Son Joaquin Local. Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------------- - ----- --------------- Owner 4 ------------------- -title --------- e ---------------------------- (11i - (If other tha ner) - FOR .DEPARTMENT USE ONLY r APPLICATION 'ACCEPTED BY --------- --------- -------------------------=----------------------------- ------- DATE ---- r L r h------------------- BUILDINGPERMIT ISSUED ----------------- ------------------------------------------------ --------DATE -------------------------•-------------- ADDITIONAL COMMENTS ----------------------- - --------- ------ ------ --------------- ----------- ------------------ ---------- ------------------------- ----- ---- --- ----- ------- -- ------- Final Inspection by DateC 17 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M