Laserfiche WebLink
FOR OFFICE USE: L �ppLICATION FOR SANITATION PERMIT <br /> . - ---------- ., <br /> f - (Complete in Triplicate) Permit No: _� -_l�✓- <br /> ' Date►Issued - <br /> ____________________________________________________- This Permit Expires 1 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 /> TY 3 <br /> JOB ADDRESS/LOCATION. ------- ----s -----------------------------CENSUS TRACT ----------------_--- <br /> Owner's Name ---------- LQl '------- - ------------ ------------------------­--I-- - - -----Phone ----------- ------------------------ <br /> Address <br /> ------ - - -- ---- - - - - - - <br /> Contractor's Name ---------------------- -- - ----*�-- ---------------------.License # ---- Phone .............................. <br /> Installation will serve: ResidenceIkApartment House-[:) Commercigl ❑Trailer Court ❑ <br /> Motel ❑Other--------------------------------- <br /> Number of living units:____[____ Number of bedrooms ___ _Garbage Grinder ___ ____;_ Lot Size/._ _ 7 .____-.._- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------- ------ ..........Private.El <br /> Character of soil to a depth of 3 feet:-i 5gnd'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam :❑ <br /> Hardpan ❑ Adobe Fill Material ___________ L, <br /> iyea;type ---------------_------------ <br /> � <br /> (Plot plan, showing size of lot, locatidn 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,) <br /> --77GG <br /> PACKAGE TREATMENT [ ] SEPTIC TANK S _________ Liquid Depth --------151!.7 <br /> Capacity _L Type __ _.._ Material-- ---- - a. Compartmehts <br /> Z <br /> Distance to nearest: Well- ------------------------------------Fo dalion ___ ---------------- Prop. Line ...................... <br /> LEACHING LINE Inl No. of Lines _________r___________ Length of—ea (in "af __�_____ Total Length _____�/_ _.. <br /> --- ------ .........�r r/ <br /> 'D' Box ------------ Type Filter Material __. _______Depth Filter Material ----lv_---------________________________ <br /> `Distance to nearest: Well ----------------_______i Fo6ndation -----------------I------ Property Line -------------- __.------ <br /> S C E-PR-PR [ j Depth _____I+Q__i__ ___ Diameter y_X4t___ Number ------/________---__��. Rock Filled Filed Yes � No 0 <br /> c Water Table Depth ------------------------------------------------Rock Size IX �L----?.---- <br /> Distance to neare i,Ielll ________________________________________Foundation ___,�Q__-___-.,Prop. Line ...................... <br /> 1. <br /> REPAIR/ADDITION(Prev. Sanitation.Permit# ________________ ________________ Date ----------------,-----------------} .. <br /> Septic Tank (Specify Requirements) - -------------------------------------------- <br /> Disposal <br /> ----------------------------------------------- -- ----- <br /> s <br /> Disposal Field (Specify Requirements) ___________ ______-___\ ______________________________________ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation-laws of-Cal}ornia."t, <br /> Signed ----------------------------------------- -------- --- Owner <br /> By --------------------------/G�4�/--------- ---p---- Title ------------------------------ <br /> (If other than o r) <br /> F PARTMENT USE ONLY17 1 <br /> / <br /> APPLICATION ACCEPTED BY --------------------------------------------------------- DATE E - --------- <br /> --------------- <br /> BUILDING <br /> PERMIT ISSUED ------ --({<-�- ---- <br /> ------- ------- - --- ---------------------------------DATE -------- ------------- ----------- <br /> ADDITIONAL <br /> - ------ <br /> ADDITIONAL COMMENTS ------ -------- ----------- ------------------------------------------ ---------- <br /> -------�-�------------- <br /> -- <br /> " <br /> ________ _ _ :_______:___=___ _ ___ __: _________:_________.__:____==__-:____ .____ ___ _ _____-_� �:___ __=_=="�� <br /> ------------ ------�-- ------ ----- = -_=--:___�_.- -- - _- _ :_____: _ _ ._ - . . _ <br /> ------------------------- ------- --------------------------------------------------- <br /> Final <br /> Ins ection by - _ Date __--------___----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1-'68 Rev. 5M <br />