Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATIOWFOR,SANITATION PERMIT <br /> ----------------------- <br /> -------------------3- --- �= 2 <br /> (Complete in Triplicate) Permit No. <br /> This,Permit Expires 1 Year From Date Issued Date Issued __ _--�=l- <br /> 4 <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 co iiance with County Ordinance No. 549 and existing Rules and Regulations- <br /> , *, Y, N <br /> JOB ADDRESS/LOCATION .-- _. __--' --- � _ _ ° fw CENSUS TRACT -------------- ----------- <br /> JOB <br /> Name -- J/-,!;'7-1----- A ` Z ---------------------------------------------------------------------------Phone .-.--------= <br /> Address _- !� � t� 4r,!..... " '/ --_ . City _ < k"�2------------ ------------------------------ <br /> Phone --------------------------- <br /> - y Phone _ #e <br /> Contractor's Name ____/ �-� ---------------------- __.License #Ipf,-- ------ <br /> Installation will serve: Residence `Apartment House,❑ Commercial�❑Trailer Court ;❑x <br /> Motel ❑Other ---------------- y---- ------ N <br /> it <br /> / <br /> Number of living units:_._1___.. Number of bedrooms ___.__Garbage Grinder _._ � 7_ Lot <br /> -- �~ <br /> 4 <br /> Water Supply: Public System and name���"f��-�"f�-�-�'---'--�-$�--��---��-'------4,-�;----- - -- -------------- _____Private ❑ <br /> € <br /> Character of soil to a depth of 3 feet: Sand❑ Silt;❑ Clay ❑ &d ElSan'dy Loam E] Clay Loam <br /> Hardpan F1Adobe F-1Fill Material------------ If yes, type _______.__________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ` _.-w <br /> �t <br /> PACKAGE TREATMENT [ ] SEPTIC TANK-A Size__ , ___X__9)--------_____________•Liquid Depth ------ J <br /> Capacity Imp©-,--- Type e r Material_4ewll `_____ No. Compartments __ --------------- <br /> Distance <br /> ________ ____Distance to nearest: Well -----------------__Foundation __Z_1*------------ Prop. Line _ZA1---____-__ <br /> LEACHING LINE Y' No. of Liries ------�______.__-__ Length of each line----- Total Length /tr --------------- <br /> 4; <br /> 'D' Box/_.A_$_ Type Filter Material�g_J Depth Filter .Material ��_________________________________ p <br /> Distance to nearest: Well ....___________-------- Foundation ___ _ ------------- Property Line ------------ <br /> SEEPAGE PIT rk/ Depth ------- Diameter %„ - ------ Number _____��-_________________ Rock Filled Yes No ] <br /> Water Table Depth * <br /> /--------------------------- Size �.`_ C__: ,(-------- <br /> Water 1 <br /> �-.-- ----_------------ <br /> Distance , <br /> to nearest: Well ________________________________________Foundation _ - p. ~ <br /> ________ Pro Line '} <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----- ------------------------------------- Date _____________--________________-_} <br /> Septic Tank (Specify Requirements) ---------------------------- ----------------------------------I------------- --...--------------------------- <br /> Disposal Field (Specify. Require'ments) -------------------------------•------------------------------------------------ ------' <br /> ----------------------------------------------=------------------------------------------------------------------------------ --------- ----------------------------------- --------- ----------- <br /> j'l f <br /> ----- ------------------------------(Draw ex----n and re u ed addition on r > <br /> ----- -- -- --- ----------- - ---- --- ------------- <br /> I hereby certify that I have prepared thisxappli ation and that the work will <br /> side) . ui <br /> 'slI b�ednin 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 /> h "I certify that in the performance of the Work for which this,permit,is.ssuedl. 1 shall not empley any p@rson iii`-suehinanner <br /> ii <br /> as to become subject to Workman's Compensation lowseof California." { <br /> Signed - -�y----------------- Owner +r <br /> ----------- <br /> By.,.------------------------------ ---- ---- Title ------ -------------------�---------------- <br /> (if <br /> --------------- <br /> (if other tha wner) <br /> R�:D TMENT USE ONLY r <br /> APPLICATION ACCEPTED BY ------- - ------- ------- --------------------------------------------------- ATE -- „ 7�-------------------- <br /> BUILDING PERMIT ISSUED_--------- -- ------- --- - ---- - - -------- -------------------------------------------------------DATE ------------ ------------------------------ <br /> 4 AbDITIONAL COMM TS _____ __ <br /> -------------------------- - ------------------------------ <br /> a_. - -- _--- - ------#------row,-1......... <br /> !if - - - <br /> - ------------------ ----- ---------------------- -------------------- <br /> ---------------------------- ---------- --- ---- -------- - ------------------------------------------------------------ ----------- --- --------------- --------------------=------- <br /> Final Inspection by: �� V --------------------------- ------ --,,ate __ - ---------------------- <br /> AN,YOAUIN LOiALH.EALTH DISTRACT <br /> .. E Ff{9.� -14 6B Rev: 51V1 <br />