Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
FOR OFFICE USE: t ` <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- <br /> lComplete in Triplicate) Permit Na. __� :_A _�. <br /> - - <br /> --------- ---------------- -- 4 , r/ <br /> /� f - Date Issued /G 7 1=6d <br /> ____________ __ --- ______-_____ r This Permit Expires 1 Year From Date Issued ;1 ^` " <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> �� 1 <br /> JOB ADDRESS/LOC ION . -- :- -- ----------------- -----CENSUS TRACT --•----------- ----------- <br /> Owner s Name -_ ----------Phone ------------- <br /> Address _ ?Z53_,a � ------ -------------------------------------- Cit <br /> Y <br /> Contractor's Name - (_fit- -------- ----- --- ---------.License # --'Phone _'51 _41o _ <br /> Installation will serve: Residence X-Apartment House❑ Commercial :❑Trailer Court ❑ �I <br /> Motel ❑Other ---------------------------------------- <br /> Number of living units:____ __-- Number of bedrooms ______Garbage Grinder ___________ Lot Size. _ __�/4'.0 ........... r <br /> Water Supply: Public System and name ------- <br /> - <br /> ----- -- ------------------------------------Private El <br /> Character of soil to a depth of 3 feet: Sand❑ - Silt❑ Clay .❑ Peat❑ Sandy Loam -❑ Clay Loam ,0 <br /> Hardp <br /> an ❑� , Adobe Fill Materialv_ � :_____ 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 avdilable within 200 feet,} <br /> PACKAGE TREATMENT <br /> [ ] SEPTIC TANK'[ a Size -------•--------------------------- ----` Liquid Depth --------------.._......... \ <br /> Capacity -------------------- Type -------------------- Material------------ ------ No. Compartments ------------- <br /> Distance to nearest: Well ------------------------------------Foundation ,________`_______-___ Prop. Line __-__-•-__---___-_____ } <br /> LEACHING LINE [ ] No, of Lines ------------------------ Length of each line---------------------------- Total Length _______________----.----___. <br /> 'D' Box ------------ Type Filter Material- ---------------------Depth Filter,Material ------------------------------------------ <br /> Distance <br /> ________________________________________Distance to nearest: Well --------y-------------- Foundation _______________________ Property Line. -------------- ........ <br /> SEEPAGE PIT [ } Depth _________________ __ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No I❑ J <br /> Water Table Depth ------------------------------------------------Rock Size --;----------------------------- <br /> Distance to nearest: Well _______________________________________Foundation ------------------.. Prop. Line ------------_-------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________________ Date ------------------..__.....-------j I <br /> Septic Tank (Specify Requirements) _ ___ _ _-. G(; - <br /> --------- <br /> Disposal <br /> _-------Dis osal Field (Spe i YRe Requirements) _____ ________ --------�©---------------- <br /> Y <br /> ------------------------ ----- <br /> ---- - - - ----------andre -- ----- <br /> g q <br /> (Draw existin aired addition on reverse sid }e <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 bec me s bject to rkm 's Compensati. laws of alifo nia." <br /> Signed ----- �Y1- =---- ---- wner <br /> BY ------------------------------------------------------------- 4 ------ -- Title ------------------- <br /> (If other than owner) �t <br /> on FOR DEPA1tTMENT USE ONLY <br /> APPLICATION ACCEPTED BYcir{ ---------------------------------------------- DATE ��' � �� ---------- <br /> BUILDINGPERMIT ISSUED --------------------------------- ------------ -- ----------------=--------------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS -------------------------------- - X <br /> ----------I------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- ---------- <br /> ----------- ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- --- ------ <br /> --------------------------------- } <br /> ,�f <br /> Final Inspection by: - fes' --Date .-_4:. 1 - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` E. H. 9 1-'68 Rev. 5M <br />