Laserfiche WebLink
rOR OFFICE USE: <br /> " " {"""" " �" "" ""� "�" I APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate}_ Permit No: <br /> This Permit Expires I Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District`for a per 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 .---------_ Z <br /> ° --- -------------------"CENSUS TRACT ___y_-------------------- <br /> Owner's Name �r--------------------------------------------------------- -- Phone <br /> Address ___5 __ C-----c J ----------------- -----. City ---cam _ !''~� ........... ---------_--•---•---- <br /> Contractor's Name ------- f1-war _' = ".".". -----------------------------Licer6 # ------- ----------------- Ph no e"i'----- -----------•"--"-•--- <br /> Installation will serve: Residence' Apartment House-E].Commercial ❑Trailer Court i❑ <br /> Motel F-1Other.- t j-----�------------------------=6-- <br /> Number of living units:-------- Number of bedrooms _____ Garbage Grinder ------------ Lot <br /> Water Supply: Public System and namefa <br /> u_ _1`_G -- ____ P"�1__ '(S--- �ancly <br /> _4s�. ,_�_---------------__s_____--_.Private ❑ <br /> Character of soil to a depth of 3 feet: nd'❑ Silt❑ Ciay ❑ Peat❑ Loam -❑ Clay Loam ;❑ <br /> Hardpan ❑ Adobe Fill Material J�f_-------- If yes,type ---------------------------- <br /> (Plot <br /> --_---___(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.} `},t <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200-feet,) it <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 [ ] No. of Lines -_-___-__- ---------- Length of each line--------"------------ Total Length <br /> 'D' Box ------ Type Filter Material ___________________Depth Filter Material ----------------------- <br /> Qistance to nearest: Well ------------------------ Foundation --------- <br /> s=_'-- - Property Line ------------------------ <br /> SEEPAGE PIT [ ] Depth ------------- ----- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> --------------#----------------------•--------Rock Size -------------------------------- <br /> Water Table Depth , <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit s# -------------------------------------------- Date -----------_______________________) <br /> Septic Tank (Specify Requirements) ------- r <br /> Disposal Field (Specify Requirements) ______________ 'J- -------- ---------- r r 5 � <br /> , --------------- �--�-------- G - .:�.--- 4 r r pN'' <br /> f------------------- <br /> v <br /> ------------------------------------—-------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> n <br /> (Draw existing and required addition on reverse side) f <br /> 1 hereby certify that 1 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 )icon- <br /> sed agents signature certifies the following: H <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 became sub'e "* War 's ompensation laws of California." , <br /> Signed ------ -- ----- - --- -- - -------------------------------------- Owner <br /> By ------ ---------------------- - -- ----- - - ------------------------------------ Title ------------------ ----------------------------------------------------- <br /> (if <br /> -- --- ------ --- ---- - - <br /> (If other than owner) <br /> �1,4dlARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . --- --- ------------------------------------------------------. DATE _I Q--'� -- <br /> BUILDING PERMIT ISSUED ------- ----------- ----------------------- ----- -- ---- -DATE -- ---------------------------------------- <br /> ADDITIONAL COMMENTS ---- ---- - ------------ ---------------------------------------------------------------------------------=----------------=---------- <br /> -------------------------------------------- - -f <br /> -------- -----------------------------------------------------------------------•---------------------------------•-_--•-- <br /> ------------------------------------------ -------------------------=----------------------------------------------------------------•------------------------------------------------------------ <br /> --------------------------------------------------------------`---------------- <br /> Final inspection by: _1 = Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT lL <br /> E. H. 9 1-'68 Rev. 5M <br />