Laserfiche WebLink
FOR'OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------7-=�--�T -- -------- <br /> - A Permit Na: <br /> (Complete in Triplicate) <br /> --------- ---------------- ----------------=----- <br /> Date Issued _77- G. __. <br /> r <br /> This Permit Expires 1 Year From Date Issued <br /> ----------------------------•------------ <br /> �p <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 compl' nce with County Ordinance No. 549 and a 'sting Rules and Regulations: <br /> r 1 �� <br /> �2 ' � ---- r� ` -CENSUS TRACT --------------_ --------- <br /> JOB ADDRESS/LOCATION .7 ------------= = ------------------�= <br /> 4 Owner's Name ------- / 1--- ----- -Phone ------------------------------------ <br /> �/ .,� <br /> Address'?tib --- C��� _._:J �' uld _,. Z� <br /> -- City - ��� -- <br /> Contractor's Name ---------------� ------- ----- - --------------( "�--------.License # f1"-- one <br /> Installation will serve: Resident0 <br /> artment House <br /> f❑ �Commercial[]Trailer Court ;❑ <br /> �M Motel ❑Other' --`"t <br /> Number of living units:-__`__ _ Number of bedrooms __ ___Garbage Gr'nde Lot Size _, 4 -------------- ----------- <br /> . 1�J , - ----------------------------------- <br /> Water Supply: Public System and name '�--- - ---=----- am -Private ❑ <br /> - - - - -Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Lo ❑ ` Clay Loam <br /> i <br /> Hardpan ❑ Adobe-E] 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 ewer is available within 200 feet,). <br /> PACKAGE TREATMENT [ <br /> SEPTIC TANK ize-__ _91------------------ Liquid Depth ---'�"---------•---.----- <br /> capacity �--- -- TYpe. �------- <br /> Material j ----- No. Compartments �. ........... <br /> Distance to nearest:/ _ Length <br /> _____ _ --------Foundation _,� -.________ Prop. Line]-___� - � <br /> LEACHING LINE [ ] No. of Lines ---------/-----_____._ of each line_.---------------- Total Length.., ------------- <br /> 9 .., <br /> - --.(�------------------ <br /> 'iD' Box ------------ Type Filter MaterialSf -Depth Filter Material __ _______________________________ <br /> D,l <br /> istance to nearest: Well ________________________ Foundation ------------------------ Property Line ___._____-______--,---- <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ----------- ---- Number ---------------------------- Rock Filled Yes ❑ No_I❑.E <br /> r lDater Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> t <br /> Distance to nearest: Well ----------------------------------------Foundation"-"'_---------------- Prop. Line -----..._-______--__-. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------ ------ Date ______.___________----------------) + <br /> SepticTank (Specify Requirements) ----------------------------------------------------------- ------------ -------F------ ----------------y­--------------------------- <br /> Disposal <br /> ----i--------------------- <br /> Disposal Field (Specify Requirements) ` 4A'r <br /> --------------------------------------- =-----• ---- ----------- <br /> k <br /> i1 i r, » <br /> __________________________________________________________________________________ <br /> I <br /> i -------- ---- -- - - - - --- -------- --- <br /> I� (Draw existing -and required addition on'rev erse side) �r <br /> I hereby certify that I have prepared this application and that the work ;will bei done in accordance•)wilh San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Fleslth 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 p rmit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation la ofriForn• <br /> : ....._ _._ .� <br /> tSig --- ------ ---- ---- '-t------------ -- --------------- -------- --- ------ ner <br /> • - ,� <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY r <br /> BUILDCNG OPERM TACCEPTED <br /> ISSUEDBY r � _ DATE ----� --��_-G�- ------ <br /> --------------------/ ----_-__-- ----------- ---------------- -------DATE - ------------- <br /> ADDITIONAL COMMENT <br /> ,I <br /> r <br /> -------------------- --- ,.w ------- r -- <br /> -------------------------------------------------------- - - ------ <br /> Final InspectiobY: I = ----- - ----------------------------------------------------------- <br /> Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> jr, <br /> E. H. 9 1-'68 Rev. 5M <br />