Laserfiche WebLink
r R�r <br /> FOR OFFICE USE: <br /> / APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. r! <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application i.,&hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> describe is ap ation is made in compliance ,w(itth County Ordinance No.. 54 nd.existing Rules and Regulations: <br /> IV&:1110 <br /> JOB S5 L C I N --- I 1 �''f '""`` L "_ - --CENSUS TRACT -------------------------- <br /> - <br /> f <br /> Owner's Name f� - ----- J / � �/1,------ -•-----------------------------------%---------- --------Phone nl e s -R�/------ <br /> Address __ __- -. f'Y+ ✓ <br /> --------------------------------------------- - ------------------------------- <br /> Contractor's Name _. _. ------- ____ 12_/ ---------- <br /> ------------------License # C7 1-� __ Phone _ s _ b- <br /> Installation will serve: Residence ❑ Apartment House,[-] Commercial NTrailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms ____________Garbage Grinder ___________ Lot Size �-d�d�_-- ------------------ <br /> ... \ <br /> Water Supply: Public System and name -----------------------------------•---------------------------------------------------------------------------Private [ <br /> Character of soil to a depth of 3 feet: Sand'[,g Silt❑ Clay ❑ Peat❑ Sandy Loam .❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ___________ If yes,type ____________________________ <br /> _ V <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLAT1014: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------&'.?c ?C_a..__. Liquid Depth -' ----------------- <br /> Capacity/ _a______ Type " _ Material__ No. Compartments ...................... <br /> Distance to nearest: Well -----� ___ _________________Foundation _/ ._.__________ Prop. Line <br /> ``-------------:-------- <br /> LEACHING LINE [ ] No. of Lines ____�'______________ Length of each line_._..-20_------_______ Total Lenges /Yo............... <br /> 4. <br /> 'D' Box __/______ Type Filter Material /�� ____Depth Filter Material -/.V________________________------- <br /> Distance to nearest: Well -----1�--f----- Foundation -----�_C>.---------- Property Line ___. <br /> SEEPAGE PIT [ ] Depth ____ Diameter ___------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------•-- -------.Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation --------------------- Prop. Line _________---____.__--- <br /> REPAIRJADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------- --------------------------------------------------------------•----------------------------------------- --------------- <br /> DisposalField (Specify Requirements) ----------- ------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------•--------------••--------- <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 /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California. <br /> Signed -- -- _. Owner <br /> ------------- -- - <br /> ---------------------------- - ---- ----- <br /> ------------- <br /> By ------- - --- - - - Title --------- ---- <br /> --------------- <br /> (If other than owner) <br /> FQR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------- �"---------------------------------------------- DATE ---- <br /> BUILDING PERMIT ISSUED ------------------ ---------------------------------------- --------------------------------------------DATE -------- ---- ----------------------------- <br /> -- <br /> ADDITIONAL COMMENTS - <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------- <br /> ------------------------ - ---------------------------- <br /> Final Inspection by: ------- <br /> -------- Date r ` " ((�� <br /> ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />