Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br />...............I.................... _.......... <br /> (Complete in Triplicate) Permit No. _ ........ ... .. <br /> Date Issued a. .7. � <br /> This Permit Expires f Year From date Issued .... <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/LO ION 17 ............... ... tee..., _._. ..CENSUS TRACT ......_ :J <br /> i <br /> Owner's Name ._. .... � .. _ ........ :._. Phone .............. <br /> !f <br /> Address / �� _.. feY- City c ..._ ,� .....Cl._ ....._. <br /> Contractor's Name ....... •..... ......n._.License # .f 'f ... Phone ............................... <br /> Installation will serve: Residence Q Apartment House(] Commercial ❑Trailer Court fx x,641� <br /> Motel ❑Otherx m A <br /> Number of living units:_.._..._ Number of bedrooms...-. r....Garbage Grinder _._.�. ... Lot Size ....................... ` <br /> Water Supply: Public System and name -----. .. <br /> ----- - - • --- -• ------- �:.. - -------••-----.....-•-------------- ......Private [] _ <br /> Character of soil to a depth of 3 feet: Sand <br /> 0 Silt❑ Clay ❑ Peat Sandy Loam ❑ Clay Loam ❑ � <br /> 0 Fill Material ............ if es, <br /> Hardpan ❑ Adobe � � <br /> Y type -••-•------------•--•--•--.. <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,j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size----------------------_-----.._._...._...----. Liquid Depth .....-_..........I....... <br /> . � <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' Bax ............ Type Filter Material ....................Depth Filter Material ............................................ I <br /> Distance to nearest: Well ........................ Foundation Property Line ........................ <br /> SEEPAGE PIT [ ) Depth Diameter ...........:.... Number -----------___........... Rock Filled Yes ❑ No { <br /> Water Table Depth .................................................Rock Size ................................. <br /> Distance to nearest: Well ...................................•....Foundation .................... Prop. Line ...................... � <br /> { <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date __............................. <br /> ---) <br /> Septic Tank (Specify Requirements) ...............................•--------- ...............................-•-----•--•.----•--............ ---.......,_......... I <br /> isposa! Field (Specify Requirements) ._ ".e" •• � +-_ •-...___• • _..-.•'-..•- -------------- �; <br /> ------------------Q+�---- ----------••- le <br /> ld� .. �� <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 /> "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 /> Signed --------------- ---------...._.... - Owner <br /> By <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------------------*. ---- --...... DATE .'S .............. <br /> BUILDINGPERMIT ISSUED -•...............:................................................................................ ------ _-•--•..............DATE --•------- -••............................ <br /> ADDITIONAL COMMENTS ............ ............................ __............_......_......... <br /> .........................i:- <br /> .e............ --41� <br /> ..••---••-----........----------••-----•-----•-•-•----------4"­...... <br /> ..............Date------ • •------•- .....-•------------- .......Final Inspection by: -�- 7�_...._.....•• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTp <br /> c u 13 24■ <br />