Laserfiche WebLink
FOR OFFICE USE: <br /> =_'O = DD___O T APPLICATION FOR SANITATION PERMIT <br /> ------------------- <br /> ' (Complete in Triplicate) Permit NG, U_ ��- . <br /> Date Issued __..- ?7G> <br /> -- -------- ---------- - - <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 complian ce with C my Ordinance No. 549 and existing Rules and Regulations: <br /> ---- .?__ ----____--//__E- ---- - -- -- --- -- - --dr��- <br /> -----CENSUS TRACT ----------:--------------- <br /> JOB ADDRESS/LOCATOwner's Name !- -------------- --- Phone 7-Wir--d <br /> Address - City --- ------------------------------•------ <br /> zlwl <br /> Contractor's Name __._____________.. __ _ __ ___ ___________License #/ ,�'�1r___ Phone �_' Q_ <br /> Installation will serve: Residence ❑Apartment Ho se,❑ Commercia ❑Trailer Court <br /> Motel ❑Other ______ _ _ __ <br /> Number of living units:___ ----- Number of bedrooms _.-!------Garbagrin er _______ Lot Size'--� .. .�_ ................. <br /> Water Supply: Public System and name ----------------------------------------------- - ------------------------------------Private ❑ <br /> Character of soil to a depth of 3,feet Sand'M Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan Adobe Fill Material ------------ If yes, type _ "V <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,) YYY <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ____-__________--_....._ <br /> Capacity --------------- Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well ____--___-_______.__Y_____________Foundation ---------------------- Prop. Line -___________-__.__---- <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length -----------_-------------- <br /> 'D' <br /> ____.-__- _.___._-___---__'D' Box ------------ Type Filter Material --------------------Depth, Filter Material -_:________.___-._-____---_-___---.__-- <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 /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ____.__-__--___________-___-______) <br /> SepticTank (Specify Requirements) ------------------- -------------------------------------------------------------------------------------------.---------------------------- <br /> Disposal Field (Specify Requirements) ----------- - - ----- r ----------------- --------------- <br /> _ <br /> c� ------------- <br /> - ------ -----7-- ---/' �'- <br /> x_- .� - - ---- <br /> - - -- - -- - <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this ap0lic0ion 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 ------------- --- ------- ------------------------------------- Title --- - - ------ ----------- ----------------- <br /> (If oth han owner) <br /> FOR PEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _- - -P_ -__.. _ ._f� DATE -S-_.�__._ ________. <br /> ----------------------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------- --- ---------------------------------------•--------------DATE -------------- ---------------------------- <br /> ADDITIONAL COMMENTS - - = <br /> -------------------------------------------------------------------------------------------- -.-------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------ ----------- -- <br /> _ <br /> -- --- ------------ ------------------------------------------------------ - ---------------------------------------------------- <br /> ------------------------------------- ------- <br /> ----- -- ------ ------------- - - <br /> Final Inspection by: --- -------- ------------------------------------------Date - -� �� ------ <br /> SAN JOAQ IN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />