Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: <br /> ------ <br /> ---- !' _--------__.------_--------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued Ja-_�3_:..7y <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 --- - -_"`a f-------- �+�i C' -c' j a`H:-------- CENSUS TRACT ------ ---------------- <br /> Owner's Name ------------------------------------------------------------------------Phone ------------------------------------ <br /> t City � f' -&4------------------- <br /> Address .�_Y.-. h----- ---------------------------------- <br /> 1 <br /> Contractor's Name _.___ _ __�_a __�_�i,__.� <br /> ��'-�-�-�---t�--�- �---�-��--License #���-f-. -�=-�'--- Phone 11" <br /> s-w-4--`��------ <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -- ---------------------------------------- <br /> --- <br /> --------- ---------------------------- <br /> Number of living units;... j Number of bedrooms ______Garbage Grinder ____.L ___ Lot Size _ --- _ ______________________ <br /> Water Supply: Public System and name ----------------------------------------------------------------------------------------------------- ------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpari Adobe ❑ Fill Material ------------ If yes,type ___________________________ <br /> 0(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 /> T <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size_:_rT_____` __ ____ __-71--_ Liquid Depth __l f._�--- ----------- <br /> t� <br /> Capacity �_ '-_ D 4fi T'ype ----------------`-- Material-_Gt_4FM-f L`,-- No. Compartments -----V----------:---- <br /> Distance to nearest: Well --------5- ---------------------Foundation ---------------------- Prop. Line ----------------•-••-- <br /> . i <br /> LEACHING LINE [ ] No. of Lines ------�r----------------- Length of each line-___ U------------------ Total Length ___: --6-_--__f--___--__ <br /> 'D' Box .-I------ Type Filter Material 11.2-_- _Depth Filter Material -----)_5:_-� <br /> ---------------_ <br /> Distance to nearest: Well ____1 t ---------_- Foundation ------------------;----- Property Line ___, r_____-.--_... <br /> SEEPAGE PIT [ Depth ---�7_5-----_--- Diameter _ _ -------- Number ---___:�---- ------- ---- Rock Filled Yes [X( No i❑ <br /> Water Table Depth -------------------- ---------------------------Rock Size --�-- - --------------- <br /> Distance to nearest: Well ------1-5_A_ ------------------Foundation -------------------- Prop. Line ______._______________ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____________.__________________-_) <br /> Septic Tank (Specify Requirements) -------- -------- - ---------------------------------------------------------------------------- <br /> Disposal Field {Specify Requirements) -------------- -- -------------------------------------------------------------------------------------------------- --------------- <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 /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------------------------------------------------------------------------------- Owner <br /> BY ------------ ----- _L"� . '..'�- r i <br /> -------------------------------------------- Title ----1: <br /> --------------------------------------------------- <br /> (If other thanner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -__ --. DATE _ -,�� --7_ '--------------.. <br /> - -------------------------------------------- <br /> ----------------- <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------------------- ----------------=--------------DATE <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------- --------------------------------------------------=--------•- ---------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ---------- <br /> - --------------------------------=---------------------------------------------------------------------------------------------------------- ----------------------------------------- -- -------•-- <br /> ------------------------------- --------- --------------------- <br /> - --------- <br /> ----------------------------------------------------------- --------- - <br /> Final Inspection by: ----- `-------------------------------------------------------------------Dafie ---------~ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />