Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -----------------------------------------A} � ____(Complete in Triplicate) Permit No. _-/-.7 <br /> ---\1/ <br /> Date Issued __7 _ z� <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 /> JOB ADDRESS/LO TION_..._T_ _ _C_'_ �� <br /> �4 � ---.��- -- �rr �----------------- ._. __ .__CENSUS TRACT ----- -�-.----•---- <br /> Owner's Name I`�)r Cllj f=� ----- �' f.�------------------------------------------------------------Phone c ------ --_----------- <br /> Address <br /> - --------Address --- �) w -- ��--- <br /> P_ -- - ------- -------- City ' ` <br /> ----- -- <br /> / <br /> Contractor's Name ------6r,_-/L__..__ ___1_�?_l?_yy/� --------------- ---------------License # _ � Phone <br /> Installation will serve: Residence_jRApartment House.f❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ----- --------------------------- <br /> Number of living units:___ f- <br /> - ---- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ______________________-__________--____ <br /> Water Supply: Public System and name ---------------------------------•-------------------------------_---------------------------•---------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------------------- ----------- ------------ Liquid Depth _____-__--_____-____---- <br /> Capacity -------------------- Type -------------------- aterial --------------------- No. Compartments ........... <br /> Distance to nearest: Well _________-___ ______-_-_- _--Foundation _______-________-_ Prop. Line ------------_--- <br /> LEACHING <br /> _______ __________ �y <br /> LEACHING LINE [ ] No. of Lines _-_____________________ Length f eac line__________-______________- Total Length --------- .................. 4 <br /> D' Box ____________ Type Filter Mated Depth Filter Material _____________________________________________5 <br /> Distance to nearest: Well ________ __________ __ Foundation ____________________-__ Property Line -----------------.._..__ <br /> SEEPAGE PIT [ j Depth _________________ Diamet ______ ______ Number ___________________________ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth --------- ------------ ----------------_------Rock Size ------------ ------------------- <br /> Distance to nearest: Wel ____________ ___________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _ __________________________________________ Date ______________________________-___1 <br /> Septic Tank (Specify Requirements) -------------------- ------- •-------•------------- -------------- <br /> Disposal A Id (Specify Requireme s) ___________________________ ____________ IN____.___.__-___.___________ <br /> - - - --- - - - ----- - ----- <br /> - !` x/S l -------------•------- <br /> ------ ----- ---- <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 /> "1 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 Wor n's Compensation laws of California." <br /> Signed --- ----- r----- --------------------------------- Owner <br /> BY ------- -� ------------ -------- --, ------- -------------------------- Title ------------- --------.--------------------------------- <br /> --------------- <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------W-- <br /> ---------------------------------------------------. DATE . GS- 7-7 --------- <br /> BUILDINGPERMIT ISSUED ----- -------------------------------------------------------------------------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS -------------- ------------------------------------------------ --------------------------------------------- ------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- <br /> --------------------------- ---- -- -- ---- -------- -- --------- --- -- <br /> Final Inspection b _______________________________________Date _-__ s 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />