Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. -_ `--- -- <br /> ---------=----------------------------------------------- <br /> ______________________________________________________ This Permit Expires 1 Year from bale Issued <br /> 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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> r � <br /> JOB ADDRESS/LOCATION .---------- lv `- �� � v---------------------------------------------CENSUS TRACT -------------- ----------- <br /> Owner's Name ----L}_a1 -----�J £�E'. - - Phone?�_"_ Ieza <br /> Address —e --pe - - ---19-71-<----------------------- ---------------- City --------------------------------------------- <br /> Contractor's Name -r--------- ------------------------------------------License # 1 ----- Phone <br /> Installation will serve: Residence [ZZ Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other-----------------------------------------•-- <br /> Number of living units-------J--- Number of bedrooms ___'__Garbage Grinder ------------ Lot Size ___________________________________________ <br /> Water Supply: Public System and name -------------------------------------------------- -----------------------------------------------------------Private 5' <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 TANK'[ ] Size_______________________________________________ Liquid Depth ________________-_________ a <br /> Capacity -------------------- Type --------------- ---- aterial----------/ion <br /> -- No. Compartments `R <br /> Distance to nearest. Well --------------- ---- --------------Found -------------_------- Prop. Line __.. ................. Gti`i <br /> LEACHING LINE [ ] No. of Lines ________________________ Length each line.____ ./ Total Length ______-___..-__--_-________ L <br /> I------ <br /> D' Box ----_- Type Filter Materi ___________________D pth Filter Material ---------------------------•-•--_-----__-_-• <br /> Distance to nearest: Well __________ -------- -- FoX <br /> n ___________________-____ Property Line __________________._....SEEPAGE PIT [ ] Depth -------------------- Diameter __--______-__.__ N ________-_________-_____-___ Rock Filled Yes ❑ NoWater Table Depth ------------ ------------------------- ock Size -------------------------------- <br /> Distance to nearest: Well _ _____________________________ undation -------------------- Prop. Lime ________-._-•-----__-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------- ---------- Date _________________________________I <br /> Septic Tank (Specify Requirements) ------- ----------------------------------------------------------------------------------------- ------ <br /> Oi <br /> Disposal Field (Specify Requirements) _____________ ------------------------- ------ <br /> g' <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, I shall not employ any person in such manner <br /> as to become subject Wo man's Compensation laws of California." <br /> Signed ----- - ----- ------------- Owner <br /> BY ,- - - Title <br /> ------ -------------- - - <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ±{ DATE `�� <br /> BUILDINGPERMIT ISSUED ----------- -- --------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS - ------------- ------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------- ------- ------------------------------------------------------- --- -------------------------------------------------------- ---------------------------------------------------•- <br /> ---------------------------------------------------- - -- -- ------- - - - - - <br /> ----------------------------------------------- --- -- -- ------- ------------ --- -- - <br /> Final Inspection by: ---------------- ---------------------------------------------------------- <br /> ----------------------- -- -- ------------------- ------------------- Date ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />