Laserfiche WebLink
FOR OFFICE US E:' V__J APPLICATION FOR SANITATION PERMIT <br /> -------------- Permit No. -------- <br /> (Complete in Triplicate) <br /> This Permit Expires ] Year From Date Issued <br /> Date Issued <br /> __ <br /> --- ----------_- ------------------_- <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 _573-0,3-------- �,' ---------------=---------------CENSUS TRACT --------------•---•-•----- <br /> Owner's Name ------------------Phone <br /> Address ---------�-- a — --------------------------------------- City _-. <br /> Contractor's Name ------ - --------------------------------------------------License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial :❑Trailer Court Q <br /> Motel ❑Other -----------------------•---------------.. .- <br /> Number of living units-----/_---- Number of bedrooms _____ ----Garbage Grinder - ____ Lot Size _6_�X- llf---- --••-- <br /> Water Supply: Public System and name ---- ----------- --------------------------------------- -------- ---------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .E-] Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation ta wells, buildings, etc. must be placed on reverse side.) GI <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 [ J No. of Lines ------------------------ Length of each line---------------------------- Total Length _______--__-_____•-_-__-__.- <br /> 'D' Box ----------- Type Filter Material --------------------Depth Filter Material --------------------•--------------------•-- <br /> Distance to nearest: Well ------------------------ Foundation ----____ --------------- Property Line ________.__...----_-- <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter .--------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ------------------------------------------------Rock Size --------------•--------- ------- <br /> Distance to nearest: Well -------------------_-----------------_Foundation -------------------- Prop. Line ---------............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------------------------------------------------------p- ----------------- <br /> -----------------------------------------------­--- <br /> Disposal <br /> ---------------------- ---46 <br /> Disposal Field (Spegify Requirements) -------- .-----L1-Z ------- ---- �----- ---� ----------- <br /> ----------------- ` f� 0------------------------------------------------------------------------------------------------------------------------------•------------------------- <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 /> "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 sub;e to orkm n"s Compensation laws of California." <br /> Sign I <br /> Owner <br /> By ------------------------------- --------- -------------------------------------------- Title -------------- -------------------------------------------------------- <br /> (If other than owner) <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -- - ------------ ----------. DATE = ---------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------ - ---------------------------------------------------------DATE _------------•----------------------------- <br /> ADDITIONALCOMMENTS ---------------------------- --------------------------------------------------------------- --------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- ------------------------- ---- --------- --------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------- -- ------------- - --- -------- - ------ - -------- - ----------------------- ------ <br /> Final Inspection by: G ------- -----------------------------•--- -----------------------------------Date ----iQ= �4J <br /> SAN JOAQUIN �'" - HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />