Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> r1 Permit No. ------------ <br /> ------------ <br /> (,J --------- <br /> (Complete in Triplicate) <br /> ------=------- J--- 6 )-V�s� <br /> Date Issued ____.�_____________ <br /> ---- ----------- ---------------------------------------- This Permit Expires 1 Yqor 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 Coupt,y Or inance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA ION ----:A ' „p.� Y` <br /> ---- ------CENSUS TRACT -------------------------- <br /> Owner's Name ---- - �_Swvlui------ <br /> ------ -• -------------:--------------- Phone <br /> ,.1 <br /> Address -------------------------- �--= _. City -----------------------------------------•- <br /> Contractor's Name ------- -- ------------------------- --------------------------------------.License # --------- -------------- Phone -------------•-•-------------- <br /> Installation will serve: Residence ❑ Apartment House,❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----- 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'❑ S' 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 -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well -__________________________________Foundation .--------------------- Prop. Line ...................... 6 <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -----------._--__.__--___. (tt <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material _______--_-____----_-__-._---.--_--_.-_---- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line .................. <br /> m <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit c# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----. ---------------- ---------------------• 1 <br /> Disposal Field (Specify Requirements) :.4 +rJ"�� �t �' <br /> --------------------------------------------- ------------------------------------------------------------ ------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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, I shall not employ any person in such manner <br /> as to become subject to Work an's Compensation laws of California." <br /> Signed ----------------------------------------- Owner <br /> BY -- ------------------ ------------------------------------------- ------------------------ Title ----- ----------------- ------------------------------------------------ <br /> (If other than owner) <br /> FOR D PARTMENT USE ONLY U <br /> APPLICATION ACCEPTED BY ------------------------------- DATE - -=. Y <br /> 95 <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE -------------•------------------ - <br /> ADDITIONALCOMMENTS -----------------------------------`------------------------------------------------------------------------------------------------ ----------- > <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------- ---- ------------------------------------------- --------------------------------------------- -------------------------- <br /> ------------------------------------------------- - -------- <br /> Final Inspection by: ----------------- ��-------------------------------------------------------------------Date --.��©-- <br /> ------------- <br /> SAN JOAQUIN LOCAL HEALTH, DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />