Laserfiche WebLink
FOR OFFICE USE: Y�ppPLICATION FOR SANITATION PERMIT <br /> - Permit No: _.7_Zr._ .`- IX <br /> ------- ------------,----------- (Complete in Triplicate) <br /> ed <br /> ------- <br /> ---------------------------------- <br /> - -_�?�--= -�-•-I-�/ <br /> _ _ This Permit Expires 1 Year From Date issue Date IssuL <br /> ___________ - <br /> Application is hereby made to theySanJoaquin Local Health District for a permit to construct and install the work herein <br /> e in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> described. This application is mad <br /> s �,, `��t'�' t� -CENSUS TRACT --------------•----------- <br /> JOB ADDRESS/LOCATION .-_dam-------- ---- <br /> -----�---------- --------Phone ------------------------------------ <br /> Owners Name :C^... <br /> Address --------! 1 e----------------- -------------- ------------------------------------------------- City -----------------------------t1l : <br /> Sia `��------- <br /> ---------------- --------License # �:" ----- Phone - ------- -------- - <br /> Contractor'shame -_��"��--•�'-`"'----------------------------- i <br /> Installation will serve: Residence D&artment House,❑ Commercial ;❑Trailer Court ❑ <br /> Motel ❑Other - ------------------------------------------ /_ <br /> Number of living units:--1---.-- Number of bedrooms - -____Garbage Grinder --------- Lot Size __ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay J-1Peat ElSandy Loam ❑ Clay Loam <br /> ��.�.....� _ �R;-r - =Ad ri. _ .. ------ _'�'--------'d"' <br /> Hardpan obe ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK.[ ] Size---------------------------- Liquid Depth --------------- y.t <br /> Capacity� � TypeVP—CC'et------Mater'tclQv-�!-� 1* <br /> -- Na. Compartments - .------- -------- }� <br /> ---__-_Foundation -__�C-------- ---- Prop. Line __''�.�'1------------- y, <br /> Distance to nearest Well -�---or=-�'---------- -- /_q ! <br /> i ---.-- Length of each line-------_--i�------ ------ Total Length ---- -- 0--- - <br /> LEACHING LINE � No. of Lines -�-.--------- g <br /> 'D' Box .-V----- Type Filter Material Depth Filter�r Material __.__�- -------- ------ ------.-- <br /> _.... .� --- If <br /> Foundation _. ---------- - Property Line ._- -a-`= ------ <br /> - Distance to nearest: Well --- ------ <br /> D'iameter Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> l SEEPAGE PIT [ ] Depth ------------- <br /> ----- ----- <br /> WaterTable Depth ------------------------------------------------Rock Size ------------------- <br /> Distance to nearest: Well _---------------------------------------Foundation -------------------- Prop. Line ----•-------- -------- <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -------- -------- -------- - <br /> ------------ Date ----------------------------------I <br /> Septic Tank (Specify Requirements) ----- --------------------------------------------------------------------------------------;------------- ­ <br /> -------------------------- <br /> Disposal <br /> - - <br /> Disposal Field (Specify Requirements _______-_____------------- <br /> ------ ----------------------------------------------------- <br /> ---------- <br /> ---------------------------- <br /> ------------------ ,.. _ <br /> ----".------ _ =_°= -----= ---------------- - m _ - - ,_ _ <br /> - � <br /> l (Draw existing and required addition on reverse side)- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State taws, and Rules and Regulations of the San Joaquin Local Health-District. Home owner or licen- <br /> sed agents signature certifies the following: 11 <br /> "I <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 /> - -� - Owner <br /> Signe -------------------------------------- <br /> Title ----- --------- --------------------------- <br /> . [If other than owner) k <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- - --- ------------------------------------------ DATE <br /> --- --------------------- <br /> DAT <br /> BUILDING PERMIT ISSUED _-- ----------------: ------------------------- <br /> ADDITIONAL COMMENTS ------------- ------------------- <br /> - - -- - <br /> ------------------ ---------- <br /> -- -------------------------- ------------------------ - ----------------- --------------- <br /> .. <br /> -----------------.Date --- --' --�- ----- - - ---- <br /> Final Inspection b - <br /> SAN JOAQUIN LOCAL HE DISTRICT <br /> G� <br /> f E. H. 9 1-'66 Rev. 5M ' <br />