73-12 - Laserfiche WebLink

Home Browse Search

FOR'OFFICE USE: 3 APPLICATION FOR SANITATION--PERMIT a--'-- ------ Permit No.. (Complete in Triplicate) Permo. --73- -- - __-_--_______ ---------------------- This Permit Expires 1 Year From Date Issued Date Issued :._�_.____._...... l � 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/LOCATION ------ _CENSUS..T.RACT------------------------_ Owner's Name v_ J _I�� --------------- ----------------- --------- - ---Phone ------------------------------------ Address -- ---------------•----- -•---- Address -- -�'_ t d City ' ------------------------------------------- Contractor's Name ___ __ _ �!_. __.__ License # - �, `_ Phone .-______ ____________________ v- Installation will serve: Residence Apartment House❑ Comme`r'cial ❑Trailer Court ',❑ Motel ❑Other ` }�'+: Number of living units:__ Number of bedrooms . Garbage Grinder% Lot Size Water Supply: Public System and name ----------------- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑f ; Sandy Loam ❑ Clay Loam gr Hardpan ❑ Adobe'❑ Fill Material --__-. -__ If yes,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 7---------------------- Liquid Depth ------------------------ Capacity -------------- .M_._ Ca acit -------------------- Material---------------------- No. Compartments --- 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 Foundation ------------------------ Property Line ------------------------- SEEPAGE PIT [ ] Depth -------------------- Diameter -------------- Number - -__. __. Rock Filled Yes ❑ No �❑ Water Table Depth ---------- -- ------------------- --------Rock Size - -- r _ Distance to nearest: Well -----------------------------------------Foundation--_--. __�._. . Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ______. - -- Date ______ * _ . Septic'Tank K.# (Specif;y, Requirements) __ __ _ __ _ _ y __ __ _ -_ Disposal` . Field (Specif equirements) . = - - ------------------------- -------------------- -------------------- (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 wner 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 personinsuch manner as to become subject to Workman's Compensation laws of California." i - . Signed ---- ----------------- --- ------- Owner �- BY ------- ----- - --- - Title ---- --- '---- '' ` . - (If othe an owner) FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY . '~ - -- - - ------ ------ ---- -- `.DATE BUILDING PERMIT ISSUED ------ - - --- ----` DATE .------------------------------------------ -------- ------------------------ ------ - 1 f -- ADDITIONAL COMMENTS @� -------------- ------------------------------ ------- -------------------------------- --------------------------- - -=------------------------------ --------- -------- --------------- Final Inspection --- by: _�,` '_r' - --------------Date _. L�j/(� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M a q