Laserfiche WebLink
'FOR OFFICE USE: <br /> /0 30 APPLICATION FOR SANITATION PERMIT <br /> ------ -------�­­-- ------------------- <br /> -- <br /> Permit No.(Complete in Triplicate) <br /> I <br /> --- -- --- io—A- - ---------- ----------- 7 <br /> This Permit Expires I Year From Date Issued Date Issued ------------------- <br /> 0 ----------- This <br /> is hereby made to the Son Joaquin Local Health District for a per'mit 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 /> JOB ADDRESS/LOCA'�'ION --------- ........... ------------------- ---- ------CENSUS TRACT ---------- <br /> t <br /> Owner's Name 4- <br /> -------------------- ------------------------ <br /> -- -- ------ ---------------------- <br /> - ------------ - -------- --------4------ <br /> Cl/ <br /> ------------- City <br /> Address ----- --------------------- <br /> ----------------License # A_:�75QZ3---- Phone Y <br /> C6ntractor's Name ----- --- <br /> Installation will serve.., Residence [jKpa`rtment House ffl Commercial :E]Trailer Court <br /> Motel [] Other -------------------------------------------- <br /> -------------------------------- <br /> t: Lot Size <br /> Number of living uni s;----- Numbekr of bedrooms ______Garbage Garbage Grinder ----------- <br /> El <br /> Private <br /> Water Supply: Public System and name-----------------------------------------------I---------------------- <br /> depth of 3 feet: Sand'❑ Silt:E] Clay E] Peat [:1 Sandy Loam -E] Clay Loam ❑ <br /> Character of soil to a — <br /> Hardpan E] Adobe X 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.ge pit permitted.if public sewer is available within 200 feet,)z k j , - — .- - . <br /> PACKAGE-TREATMENT SEPTIC TANK'[']- - — _-:----------------------- Liquid Depth -------------I-------------- <br /> Capacity ----- -------------- type -------------------- Material---------- ----------- No. Compartments ----------------- <br /> Distance to nearest:jWell--------------------------------------Foundation ---------------------- Prop. Line .--•-----------:------ <br /> LEACHING <br /> _----------- ------ <br /> LEACHING LINE 'NNo. of Lines ------------------------ Length of each line---'------------------------ Total Length ------------_--------------- <br /> 'D' Box------------- Type Filter Material ____________________Depth Filter Material -------------------------------------------- <br /> Distance to nearest:'WellFoundation --------- ---------------- Property�Line ------------------------ <br /> SEEPAGE PIT Depth ----- -------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes 0 NoJo <br /> Water Table Depth --------------------------- :.---------_._-----Rock Size............. ----------------- <br /> Distance to nearest-, Well -------------------------------•--------Foundation ------ Line ------------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------- * 1 <br /> --------------- Date ------- ---------- <br /> ---------------- <br /> Septic Tank (Specify Requirements) -------- -------- - ----------- ---- ------- -------------------------- <br /> ---------- ------------ - <br /> - - - -------- <br /> Disposal Field {Specify Requirements) _,:124----/ --------------------------------- <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 Son 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 *hall not employ any person in such manner <br /> as to becomes b' t,t0/)AZforans Comp"anon laws ti I s of California." <br /> Signed -- <br /> --------------------- Owner <br /> By ------------------- -------t� Title -------------------------- ----------- -------------------------------- <br /> ------- - -- - ------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- <L---------- -- -------------------- , DATE ------ ----------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------- ---------------------------DATE ------------------------------------ ----- <br /> ADDITIONALCOMMENTS ---------- ----------------------------------------------------- ------------------------- ------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------;:---------- ---------------------------- --------------------------------------- <br /> ------------ <br /> -------------------------------------------- --- -------I----------------------------------------------------------------------------�1_,Z�9_ ------------ <br /> Date - --------- <br /> Final Inspection by: ------ ------------------------------------------------------------------------------------- I------(--(7 <br /> - - --- ----------- ----------- ___\-------------------------------------------------------------------------- ----------------------- --------- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 -'68 Rev. 5M <br />