Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
FOR OFFICE USE: <br /> 3 APPLICATION FOR SANITATION PERMIT <br /> ............. ... Permit No. .�_5.. 3 <br /> (Complete in Triplicate) <br /> .......... rA....................• This Permit Expires 1 Year From Date Issued 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 w t County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT N ..-.- :/. _-. .--. >��....CENSUS TRACT .......................... <br /> ...- . 1111. <br /> Owner's Name 1111..-. .... ...... ....Phone ® �.. . <br /> ......1111 <br /> 1111..---- --- -�� <br /> Address .......... .. City <br /> Contractor's Name 1111 - ...�.�� .r.:. -- '` = - License # ........................ Phone <br /> Installation will serve: Resident partment House❑ Commercial ❑Trailer Court ❑ <br /> Mate ❑ Ot [. <br /> Number of living units:.;..... Number of bedrooms Garbage Grinder ......:..... Lot Size ... . .....111:1.. <br /> Water Supply: Public System and name ..........................................-•--•----- -:-----:-------------------------11-1-1................PrivateCO__,. <br /> Character of.soil to a depth of 3 feet: Sand'❑ Silt❑ 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 TAN ize.. -- ....................... Liquid Depth 1111--.-.................. <br /> Capacity....-.•-= Type ..-.-•._ Material- .`D ,..... No. Compartments ---sCt_.•--._------ <br /> Distance to nearest: Well 0647-".434-`-,•___...,Foundation .i. .�...... Prop. Line . ' .._. ....: ' <br /> LEACHING LINE No. of Lines ��r Length of each line 4QeD <br /> _ .............. Total Length 1111-�.��...�r...: <br /> D' Box .. Type Filter Material, '111 ----_ -.. ._ -. <br /> ..Depth Filter Material 1. �. <br /> Distance to nearest: Well Fo dation ........................ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth Diameter ---------- -Number ------ Rock Filled Yes ❑ No <br /> Water Table Depth ----------------------------------------------.-Rock Size ............................ <br /> ;... <br /> F <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ........1.......111... <br /> REPAIR/ADDITION(Prev. Sanitation'Permit# ..................1 ---------- Date ......--..11 ..........----------I <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requiremerifs) . .w =--------- ----------------------------------- -------------- .... .............. <br /> .1111.--.-.-..-1111.--..-1111...... ..T------------------------------------------------- ---- - ---- -�.... -.-. _ ..-... -.. .......-.-1111 <br /> ....................1111. .-1111 -_._11.11.._. -..-......... .....c_....................-1111..,................--.......,......................................... ........................................ <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 Lows, and Rules and Regulations of the Son Joaquin Local Health District, Hone 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 s bie to Workman's C ensation laws of California." ` <br /> , <br /> Signed .I <.� � �� .. .�_f'L, ....... --=---- Owner . <br /> By ...---- 1111. �nwnerj <br /> ,+1/..4 �.....� -�� -•-�: Title . --------------- <br /> (If other t <br /> FOR:DEPARTMENT .USE ONLY <br /> APPLICATION ACCEPTED BY 1111 - %/. - �. ...-..-1111.. DATE 11117- .. ., ..� <br /> BUILDING PERMIT ISSUED --1111 ------ ....DATE ..................... .......... ....... <br /> GADDITIONAL COMMENTS .._...-•......................­­------...-•---•------------------------- ............... ----------------•--- ------ ......................... <br />- ------ ---- - ------------------ --1-- .-•-- - <br /> -- - .... <br /> . ' <br /> ................................ <br /> ....... , - -- . . . . _..... - -------------- •. . <br /> .• <br /> .. <br /> . ---....--.-•----.... . , .. 1111... _ .._ � ...... <br /> Final Inspection by.. - ------------- '- -- --------111..- - -- ... - •-1111.---------•-__Date ..... ........ ..----•- ...... <br /> f <br /> SAN JOA UIN LOCA HEALTH_ DISTRICT <br /> E. H. 13 24 1-'68 Rev. 5M <br /> .K. - <br />