Laserfiche WebLink
s <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------- <br /> (Complete in Triplicate) <br /> Permit No. <br /> /� -Date Issued _/7A-_73.. <br /> -�� <br /> --------------- �I_ ------------------------- 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 isnmade <br /> /in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION "/_Q--sem- --,-- - '--? u -7 - - --------------------------CENSUS TRACT __..___ .................. <br /> Owner's Name WiWIy!-t4_/!C--- ----------------------------------- -------------------Phone2._9"'j _3 <br /> Address -------J-__5-Q-- ------------------------------------------ city 1Q!I1' C-A-------------------------------------------- <br /> Contractor's Name .e�` -----------------------------------------------------------License --- Phone,?X ". <br /> Installation will serve: Residence [Apartment House[] Commercial [-]Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:___1----- Number of bedrooms _3_-----Garbage Grinder _'___:___ Lot SizeAD/-X /, _'/___._.._ <br /> Water Supply: Public System and name ------------------------------------- - -------------------- <br /> -------- ------------------------------------------Private l <br /> Character of soil to a depth of 3 feet: Sand'*000SiIt❑ 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.) v <br /> NEW INSTALLATION: (No septic tank or see pit per lttedifPI fseVeavail �w`ithin 200 feet,)�/ j� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size_.6// __ ---� y Liquid Depth __7` _____. <br /> ��j,,_ ---- <br /> Capacity 4�0.D-,__ Typ60i'/_1,�___�!�MaterialC©-/_y �No. Compartments - <br /> istance to nearest: Well --- -------------------•--_-___..Foundation _/_ _____________ Prop. Line ----------- <br /> LEACHING LINE [ <br /> Z. of Lines _�------_-------- Length of ach line_/1900-__-_____ Total Length�a_Q............. <br /> D' Box yt�-5 Type Filter MaterialQ&�-Depth Filter Material 1_ �i____-._ ------_.............. <br /> Distance to nearest: Well -5-0------------- <br /> Foundation /10 Property Line.a.. .................. <br /> SEEPAGE PIT [ j Depth _________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <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 <br /> ------------•--- -•• ----Disposal Field (Specify Requirements) ____________ --- <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 Workman's Compensation laws of California." <br /> Signe --- Owner <br /> B !% a"�r r� Title ] ~ -- <br /> 6 --- � � +�----------- <br /> ther t an owner) .. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- 4- = --------------------------------------------------------- DATE -----/_ ->-3-------------- <br /> BUILDING PERMIT ISSUED --------------------------------------------------------- ---------------------------- ----------- <br /> -------DATE ------------------------------------------- <br /> - <br /> ADDITIONALCOMMENTS -------- -------------------------- ---------------------------------------------------------- ---------------------------------------------------- <br /> ------------------------------------------------ ------------------------------ ----------------------- ------------------------ ------------------------------------------------ ----------------------- <br /> ------------- ---- <br /> - -------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------- - -- e3- - ------------- - - - - - ----------- <br /> Final Inspection by: --------------- = Date ®� ��� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M �'� <br />