Laserfiche WebLink
FOR OFFItE LISE: } <br /> ----------- APPLICATION FOR SANITATION PERMIT <br /> ----- - --- - - - - - - - - - Permit No: ----------._._._ .-" , <br /> / (Complete in Triplicate) <br /> ------------ `-- -- <br /> ..__._______.___ -------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued _-----.--20 <br /> _.. <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 /> S- <br /> JOB ADDRESS/LOCATION ._----/- 3I- -- --_--_- LJ _I�1 _J) _.' - - - CENSUS TRACT -----------------•--_._--- <br /> Owner's Name --------�------- I--AT [_C ------------------- -----------------------------------------------Phone ---5�3------//�77­ <br /> Address <br /> Address ------- - -3--t---------`w-------_ L }M E-I �_---------- ---------- Cit i I TI` --- -- <br /> Contractor's Name -----c, /5------- ------------ ----- -------License #;�y &&--- Phone <br /> Installation will serve: } Residence ET-Apartment House❑ Commercial:❑Trailer Court ❑ <br /> Motel ❑Other -------------------------- •••-------------- <br /> Numb of living units:-_-_-/------ Number of bedrooms __ _......Garbage Grinder WO--- Lot Size ------ _=----------.--------------- <br /> ___ <br /> Water Supply Public System and name ------ f_19_N-T_�.-_�-.-_-__GIT _-_UY1?9_TER <br /> ......._-------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam EClay Loam :❑ <br /> Hardpan F-1- Adobe'❑ Fill Material _ND--_ 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.) W <br /> NEW INSTALLATION: (No septic tank or seepage pit p rmitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size__________________________________---____,__- iquid Depth -------------------_------ <br /> 1, <br /> Capacity -------------------- Type _______ ------------ Material--------__ -__ _------ No. Compartments yr <br /> Distance to nearest: Well _______ ____________________________Foundation -------------- ------- Prop. Line ...................... <br /> LEACHING LINE [ I No. of Lines _____________ Letial <br /> th of each line---------------------------- T al Length __-.--__---_- _-_.-_.-. <br /> 'D' Box ----- ------ Type Filter Ma --------------------Depth Filter Materi I -------------------------------------------- <br /> Distance <br /> _-_--__-_____-_____-_Distance to nearest: Well ---------l_______----_. Foundation --------------------- -. Property Line ........................ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter I_______________ Number ----.-.--------------------- kock Filled Yes '❑ No i❑ <br /> Water Table Depth <br /> ------------------+-----------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well --------_ ____________________________Foundation ------------i-___. Prop. Line ...................... <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ---------------__�___---_---_---_---_.-__.-__ Date ____-____-_________-___-__-_______) <br /> s �--`c--------�- --------Tn-N!-�..----l-r- /Vr_�..------------- <br /> Septic Tank (Specify Requirements) _____-___�____ _ __ _ ___ _ ___. -- _ _ <br /> DisposalField (Specify Requirements) ----------------------------------- ------------------------------------------•------------------------------------------------------ <br /> ------------00---------OF-------- y '1 J-')F----- - <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 Wo man's Compensation laws of California." <br /> Signed Owner <br /> r <br /> BY -------- _-- ------------ Title ------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- L-= SLS ------------------------------ -------------------------------------- DATE -----5 ==1`- Y'-------------- <br /> BUILDING PERMIT ISSUED - - l -v�--------------------- -------DATE ------- -------------------------------- -- <br /> ADDITIONAL COMMENTS ------------------------------- -------------------------- - - <br /> -------------------------------- <br /> - ---------------------------------- <br /> Final Inspection by: ---------------------------------- •-------------------Date -------------- --------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />