Laserfiche WebLink
IPOR OFFICE USE:v APPLICATION FOR SANITATION PERMIT ` <br /> (Complete in Triplicate) Permit LSlo. -------------- <br /> ----------I--------------------------------------------- <br /> ---------___.------------------------------------------------------- �) <br /> � <br /> -_-----_-------_---------------_-------_---_----_ m-- <br /> -- This Permit Expires 1 Year From.-Dote Issued Date Issued/,�Y�7-_- <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 /> JOB ADDRESS/LOCATI t_ -- _ ___ ------------------------- CENSUS TRACT y--------------___p________ <br /> Owner's Name (^�,% c - -- - ---- - ---Phone 7n � G� <br /> Address ------------------- 7 aklr-- ------ City _ <br /> ---- ---------------------------------------------- <br /> Owners <br /> -- -------- ----- --- <br /> Contractor's Name ---- --- - ? ?� �� 4.Q�__License #hS7/ ------- Phone [� � <br /> Installation will serve: Residencepa"r ment House❑ Commerci6l ❑Trailer Court i❑ <br /> / Motet 1"er'------------------------------------ --- -- <br /> Number of living units:-----!____ Number-of� room's _ __1=_Garbage Grinder �f_�t�_ _ tot Siz 75--A '�__________________ <br /> Water Supply: Public System and name --------— ------------ --------------------------- --------------- - � Private ❑ <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 sexcg;r is available-within 200 feet,) f_� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size______________ �__________________-___________ Liquid Depth _________-_____-_____ <br /> --------------- Type ---- - -------- .Material--- <br /> -.--. ,- <br /> Capacity_ yp _______________ No. Compartments ...................... <br /> Distance to nearest: Well $ r ______________Foundation --------. _________ Prop. Line -_________.___________ <br /> LEACHING LINE [ ] No. of Lines _ ________ Lengthof,eacW•line---------------------------- Total Length ------_____________________ t <br /> 'D' Box ------------ Type Filter Material---------------------Depth Filter Material __________________________________________ <br /> Distance to nearest: Well ________________________'-Foundgit-ion ---- Property Line __-______________-_____ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ______- ----------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------z---------- ------- <br /> Distance to nearest: vell•:----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -,-_A-r____ _________________ Date ____________________________-____) <br /> Septic Tank (Specify Requirements) --------------------------- --------------------------------------------- ----- --------------- ---- -- -•------------------------•-- <br /> Disposal Field (Specify,/ eq ' emef ts) ---- - -- -- - ------� - ----�Q----- ------------ <br /> ----�-- x rSA <br /> ` c '?�/Q ; ----- --- <br /> �$., <br /> ------------------------ ------- .. -------`----------- K ------------ ------- - ------------------------- ------------------------------------------------------------- <br /> - ' (Drava 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 /> 1. <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 subject to Workman's Compensation laws of California." <br /> Signed ----------------- ----------- ------------ - - ----------` -= ---- -_ Owner <br /> By --------- ---- - -- ---------- - ----------- ------------------------- Title ---------- ---------------------------- ------------ <br /> (If oth h n owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- --------------`------------------------------------ DATE --- <br /> BUILDING <br /> -BUILDING PERMIT ISSUED ------------------------------------- -------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ____________________----_---- A-------- <br /> -------------------------------------------------1�-9----f- --------� f -------------------------------------------- --- ---------------------------------- <br /> -- - - -- ------ ------ -------------- - --- - ------ ------ ----------- -- <br /> Final Inspection by: `x Date � {= �� <br /> N JOAQUIN LOCAL HEALTH DISTRICT _ <br /> E. H. 9 1-'68 Rev. 5M <br />