69-934 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _(Lrl 7 (Complete in Triplicate) Permit No. -- --�- -""-'--- t Date Issued ____________________ This Permit Expires 1 Year From Date Issued Application-is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO O " CENSUS TRACT - "'_ -_- ------- ------------------------- Owner's Name _____ __ t___ __ . __ ------------------- Phone Address ---------------- -- -- ---- -�-------- - � . City - Contractor's Name ---6. ...License # -1 r .�, _ Phone ----- ----•--•-••-•--------•-- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court.-0" Motel ❑Other ------------------------------------/ylta-- Number of living units:______/__ Number of bedrooms-_.._..Garbage GriLot Size _________________•____•_________.____---- Water Supply: Public System and name --------------------------------------------------------- ------------------ ----•-------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat oam Clay Loam ❑Hardpan ❑ Adobe ❑ Fill Material _ ,type ___________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) (� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_______________________________________________ Liquid Depth __________._,_--___.___ Capacity Type -------------------- Material__-_ ______._ __ No. Compartments _ .................... p� Distance to nearest: Well ------------------------------------Foundation _______:___ Prop. Line - ............... LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length --------- .................. 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ___________________-_________-_-------_._.- Distance to nearest: Well ________________________ Foundation ________________________ Property Line ........................ SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number _________ ----------------- Rock Filled Yes ❑ No 0 Water Table Depth -----------------------------------------------Rock Size ----------- �-=----------------- Distance to nearest: Well _______ _______________________________Foundation ----------_____.____ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ....._-------------------.------------------ Date ---------------------------------- Septic _______-_-.____-_--- ___.______Septic Tank (Specify Requirements) _______ ___________________________ ____ ----------------------- - ------------------------------- Disposal Field (Specify Requirements) _________________ ----------f ' ----- -------------------------------------------------------------------------------------------------------- • ------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Wo an's Compens laws of California." Signed --- --------- --- - --- - Owner B -------- ---- -D� - _. Title - - r'" --------------------------------- (If other than owner) FOR DEPARTMENT VSE ONLY APPLICATION ACCEPTED BY - `--- - OLtAf---- --------------------- ---------------------------------------- DATE -------------- BUILDINGPERMIT ISSUED --------------------------------------------------------------- ----------- ---------------------------DATE ------------------------------------------- ADDITIONAL ---------------------- ------ADDITIONAL COMMENTS -------------------- -------------------------------------------------- - ----------------------------------- --------- ----------------- ----------------------------------------------------------- ------------------------------------------------------------ -------------------------------------------------------- ---------------------- --------------------------------- ---------- ----------- ---------------------------------------------------------------------------------------------------------------- ---r-------------------------- --------- - -- �t Final Inspection by: --- -L4---- Date - -----------------Q--------- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M