Laserfiche WebLink
\I <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> ----r -- <br /> (Complete in Triplicate) Permit No. <br /> 1 --------------------------------------------------------- This permit Expires 1 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 /> t JOB ADDRESS/LOCATION -------- CENSUS TRACT _________________________ <br /> Owner's Name -------------- --•---- ----•---------------------------_- -------------------Phone .f_X7n4?46--------- <br /> C7 .n . <br /> Address --------=f <br /> NContractor's Name -- - License # Phone _ -: - ------- <br /> Installation <br /> --- <br /> R 3 <br /> Installation will serve: Residence ❑ Apartment House,❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other / - ----------------- <br /> Number of living units_____________ Number of bedrooms __L1------Garbage Grinder ------------ Lot Size ____________________-_-_____________________ ` <br /> Water Supply: Public System and name --------------------------------------------- -------------------•---------------------------------•--•-•-----Private ❑ I <br /> 4 Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.❑ <br /> b: <br />{ Hardpan ❑ Adobe ❑ Fill Material -.----.----- If yes, type ---------------------------- <br /> (Plot <br /> ______________________-_(Plot plan, showing size of lot, location of system in relation ito 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth --------_-----------.----- <br /> Capacity - ---- ------------ Type -------------------- Material---------------------- No. Compartments ------ ----------oA <br />{ Distance to nearest: WelI __C---------------------------------Foundation ---------------------- Prop. Line ----------.---._------- <br /> l. LEACHING LINE [ ] No. of Lines ------------------------- Length of each line---------------------------- Total Length rn <br /> t -"""" 'D' Box ------------ Type Filter Material --------------------Depth Filter Material <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ------------ <br /> SEEPAGE <br /> ---_---__SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> k' Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> k <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _-______________________ Date --- <br /> -------- <br />�- Septic Tank (Specify Requirements) --------- ---_ 4_ ----/� _-- - ------------+ <br /> Efor- co <br /> Disposal Field (Specify Requirements) - ------------- <br /> raw <br /> •-- --------- <br /> fbraw 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 /> RCounty 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 ------------------------------- ----aa&---------------------------------- Owner <br /> ----/- - ' - -------------------------- Title ------ --- <br /> BY / uli ---- -- ----------------------------------------------- <br /> (If other n owner) <br /> FOR DEPARTMENT USE ONLY <br /> k <br /> APPLICATION' ACCEPTED BY ---- `— ----------------------------------- ---------------- DATE -----�- �---21------------ <br /> BUILDINGPERMIT ISSUED --------- --------------------------------------------------------------------------------=--------------DATE _.------------------------------ <br /> dADDITIONAL COMMENTS ------------------------------------------------------------------------ ---------------------------------------------------------=--------•------------------ <br /> i ------------------------------------------------------------------- ----------------------------------------------------------------------------------------- ----------- -----------------------------•- <br /> ---------- -- ----------------- <br /> - ------ --------------------=-------- <br /> ----------------=--------------------------------------------------------------- <br /> Final Inspection by: _____-- __-` <br /> ----------------------------------------------------------------------Date . l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> ,, E. H. 9 1-'68 Rev. 5M <br />